Potter, Sr. Robert NEW YORK STATE DEPARTMENT OF HEALTH , 1 `1 (a..
Vital Records Section Burial - Transit Permit
Name First Middle t I Se
0116--r)f-
Date of Death Ae If Veteran of U.S. Armed Forces,
�` a if I 3y ro War or Dates AIM
C- Place Bath / Ho . -tution or
Z City, Town r Village 3 U �, treet Address $�7 6 / ad,•.> 4� &AO
Q Manner of DeathNatural Cause D ci ent Homicide El Suicide riUndetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
i
Address T.
Death C-s ificate Filed Dis Number Re t {Number
City, own • VillageQ e'2—j�JS�' I (0,.. I
0Burial Date Cemetery Crematory
(Entombment al hi i / c()f F. ci4,6,-//.
Address l/�
Cremation LN9?Sl- .... l C 6 g y /v L / 2-Po y
I Date I Place RemoVed -
Z Removal j and/or Held
1, and/or
� Address
Hold
0 Date Point of
to Q Transportation Shipment
0, by Common Destination
Carrier
❑Disinterment Date l Cemetery Address
El Reinterment Date 1 Cemetery Address
I I
Permit Issued to I Registration Number
Name of Funeral Home 1-+6, ni;u d -b. .{J€ 1:et" Fune c c ..l ' ko `4L 1 0/l30
Address
11 L czkky c fie_ 5A. , a c.t.-C.nM DLA.r v , Ni e , NI 1._ 12 c3 t
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
fie
all
Permission is hereby ranted to dispose of the human re ains described above as indicated.
Date issued 1 `J dO I, Registrar of Vital Statistics Cam_ n, C_ ��
(signature)-
District Number`c(9 c Place ( &I 4
I certify that the remains of the decedent identified above were disposed of in a, ord. ce with this permit on:
Z
111 Date of Disposition 1 Iv iItt Place of Disposition eV V ;vw.4'}or‘`,,
2 (address)
w
in
re (section) Al_ (lot number) (grave number)
DName of Sexton or Pe on in Charge f Premises I k r, Ccei d- 34 Aelt1
(please print) ,
lij Signature i4 • Title Cu�:M t i O
• (over)
,DOH-1555 (02/2004)