Ryane, Jr. Hugh NEW YORK STATE DEPARTMENT OF HEALTH qf
Vital Records Section Burial - Transit Ftermit
`s Name First Middle 11 Last -- Sex
IQLte
!iiiiiii Date of Death Age If Veteran of U.S. Armed Forces,
. i_ � War or Dates —
...,. Place of Death - Hospital, Institution or
Ci , To or Village hal.Le- Street Address 10 /U),,,ti ,• pk
Ma of Death�� Natural C se 0 Accident El Homicide 0 Suicide ri Undetermined �Pending
Circumstances Investigation
8 Medical Certifier Name,._ Title
t' L—c,•,_ R 1)eMorz_ M ) -
Address
6'6,4 {:tlr 0�s /00 arK
iii Death Ce ificate Filed I District Number Register Number
118 Ci own r Village 4 J%1-77
1-'1'�S S _ 1
Date Cemetery or Crematory
:::.0Burial 1 / --?,/ ), vtL _ ,tom-V',c..... Lrc�4,4f
Address
Cremation aLAGeAS r pe:.� "or
ZDate 3 ) Place Removed
❑Removal and/or Held
-- and/or Address
§ Hold
Date Point of
PA❑Transportation Shipment
by Common Destination
Carrier
O
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ii Permit Issued to f:„
� ` Registration Number
> ; Name of Funeral HomeD vtS,,,,,re_ Qr,{ t- 44•c �,•c, 0O'/ ? j'
Address
' Name of Funeral Firm Making Disposition or to Whoa`
E. Remains are Shipped, If Other than Above
Address
W
X
iiffi Permission is hereby granted to dispose of the human ra ns described above as ' dicated. /
's Date Issued ) / ),/?°!'2 Registrar of Vital Statistics 1.,-6_7,10 6 ,
--r (signature) _
>' District Number`-i--i S Place to LA ,� k� le N e,✓ /o r K
r7•I
I certify that the remains of the decedent identified above were dispo d of• accordance with this permit on:
F W Date of Disposition GI�N3: /OIL Place of Disposition 1nLV�/
a...► CCO'CLriin-
i (address)
W
C (section) -(lot number) r (grave number)
GName of Sexton or Pgrso in Charge o Premises �r•sf- - orttt
z (please print)
W Signature ria\ Title ('L41m 4T0Q
(over)
DOH-1555 (9/98)