Barber, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First ro be -� Mile i- uasla_ Se
Date of Death i► ` Age If Veteran of U.S. Armed Forces,
G/1 )N/ a 0 II 1 `C War or Dates I d`"t"3 - 1+s`-'
I:- Place of Death Hospital, Institution or
401Town or Village / ) S - Street Address
-nner of Death M Natural CAe Accident D Homicide Suicide Undetermined Pending
W Circumstances Investigation
1jj Medical Certifier Name Title
a .(.:{/ -leer? M --b-
Address
131 14w A�►c.� S-�, , S�, iv, T��GG
D. th Certificate Filed District 1.Jumber Register Number
i Town or Village ,may -�r. sr- ,`f=
Burial Date Cemetery or Crematory /
...,„...7-
QEntombment 61iy7 aai► ixev,c: Crc..+1-.r
Address
ECremation k.A.Le /sc.4ul' ,4J LW `rot"(
Date V 1 Place Removed
❑Removal " and/or Held
2 F and/or Address
I= Hold
ID
0 Date Point of
05❑Transportation Shipment
0 by Common Destination
Ei Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to � Registration Number
Name of Funeral Hom ej,,t s w o re- I -[ I-(.,,,,,,, ..,,t p Q 4"71-
2_
Address
7 L e rMo.,, /.�v e-. C�a/`.- / /v aA( 1 ( 'a ,
Name of Funeral Firm Making Disposition or to Whom /
Remains are Shipped, If Other than Above
,'; Address
cr
Permission is hereby ranted to dispose of the human remains - e bo s i dicated.
Date Issued 6// ao 11 Registrar of Vital Statistics 'r Ln
(signature)
District Number Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition 10'IS-ll Place of Disposition -RV Ulm Crt' - L,r ity&
2 (address)
Ili
1
ill
CC (section) (l number) r- (grave number)
pName of Sexton or Per n in Charge of emises t,j -• --1 oil
ff! // (k/ease print)
Signature G �t Title �Q�h�t -
g p
(over)
DOH-1555 (02/2004)