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Mattison Sr, Robert , • , ll- 0 g NEW YORK STATE DEPARTMENT OF HEALTH----- Burial Transit Permit Vital Records Section =: Name First ��� �1 Middle, Last �SO�Sr• � Sex �\ ,t T .�Tb� MCt "I Date of Death I Age j If Veteran of U.S.Armed Forces, Ock 11(6 i low)( 7 Z ( War or Dates nj/ g Place of Death Hospital, Institution or City, own Village QQ 1jv� Street Address S- HS e-0, /-J "4ii im Manner of Death M Natural Cause ❑Accident 0 Homicide Suicide Undetermined Pending ILICircumstances Investigation P;j Medical Certifier Name Title C. R c * Ln.)e. MO Address 3 ‘my S� (4 2 t--TiPn S is ► IIN IZBa i Death - rficate Filed ict Nu ber a ist umber City, own Pr Village `s�]\rJ�K >- CI ! Date l Cemetery or Crematory c Z � � 2-Ia � > Li Entombment+ ;Y10 \)i a�YY\Q `n� Address- - Cremation \a� C.©ark 2 ueer\S\00� i\j \l I?S O 1-1Date Place Remodel r URemoval and/or Held and/or ' Address Hold 0 ; Date Point of ❑Transportation Shipment Ei by Common Destination Carrier Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home •C`c_1C=� TL A �`c \ Hoc,\t C711 J Address E- Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address CC Ili . Permission is hereb granted to dispose of the human remains described ab ve a indicated. Date lssuedCl lCL c)Q\,Registrar of Vital Statistics 'C_` EI n. signature) District Number Place a� n I. ate, c')-( �.r‘sL I certify that the remains of the decedent identified above were disposed of in accords a wi this permit on: Ti- la Date of Disposition �3)/0 Place of Disposition Pt7)0 U I Illetb ty a / (address) III IM (section) (lo umber) (grave number) : izi Name of Sexton o rs . Char e of Premises -S -kkLie► ri/C.L.G ie Z (please print) Via! Sig • nature Title ,re-m 6 74?r (over) DOH-1555 (02/2004)