Measeck, Ronald �.NEW YORK STATE DEPARTMENT OF HEALTH it /14
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
R on c ld, H o wo c Ineck,S ec Y, M
Date of Death Age I If Veteran of U.S. Armed Forces,
>3 03-o 2.-2 of ID lip I War or Dates 195A-- )(1 t.Q 4
44 Place of Death Hospital, Institution or
City, Town or Village Gter F-co\s Street Address Glens Falls iArS pi-kA.\
Manner of Death 12 Natural Cause Accident Homicide 0 Suicide 0 Undetermined 0 Fending
Circumstances Investigation
Medical Certifier Name Title
CI Vv ;11axv Cte— M
Address
1c O Paris &-re - C-rlenS Fal\S IQ IZ Sal
Death Certificate Filed District Number Re ter, NumbergG
`,,- Town or Village &IerS Ec \\S. �� 1
Date Cemetery or rematoryp
❑Burial 03 09- 20 t to 1);,o� V i c,J Crem..4,o„--v
Address
0 Cremation GvaYle‘r 9-d QUeenS our1 i N NI, a`s9
Date _ Place Removed
0❑Removal I and/or Held
In and/or Address
Hold
2. Date Point of
US Q Transportation , Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I Registration Number
>;_ Name of Funeral Home ,, _ R r6- P:46•1- Mfy4- 0,/SQ
Address
If c L-� t„, i. u�2as6Ot't_r - . / €f
Name of Funeral Film Making Disposition or to Whom -
Remains are Shipped, If Other than Above
Address
til
1
Permission is hereby granted to dispose of the human remains described above as indicated.
iiW Date Issued 3/4` I-h Registrar of Vital Statistics L3ct l y-Q .L�-'r '
gq
111 (signature)
District Number J 1 Place G (4r^S 'C S i N y
W
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 3^? --/4P Place of Disposition /9rrte 0 le-J (4e,114.10
2 (address)
Cl)
CC (section) , il.pt number) (grave number)
8, Name of Sexton o on- Ch rge of Premises k,/,-j,,, e:..rrt 2
Z (please print)
U' Signature Title C rennh, ir"
- (over)
DOH-1555 (9/98)