Mosher, Rodney NEW YORK STATE DEPARTMENT OF HEALTH i _K .,_ LJ
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rob,ot„-- ._ Li -(4--eft_cti- Aspfort._ /figtbr-
Date of Death Age If Veteran of U.S.Armed Fo/ces,
Z_I° f1 l `)(3 A . .r Dates Ai 4-
I-.. P - e of Death Hospita, stitution o
I own or Village C/Afp_s r-e-1 ,s - 'dress CrCe/O_S / 826.S
.nner of Death Natural Cause Accid t ❑Homicide Suicide Undetermined Pending
U "'� Circumstances Investigation
W Medical Certifier Name Title
Address
Certificate Filed District Numt�gr ( Register ber
City; wn or Village (,�^,..>,S (, c �( 0
Surial Date7 Cemetery or rematory
91/
❑Entombment Address 4„..)&f.-
Cremation
_ -- Q j-je Lam_ o �'313:
Date Place Removed ��
4 Removal and/or Held
and/or Address
: Hold
O Date Point of
3 0 Transportation _ Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home H G/nu et -b. &ler F&_ (,r CIA v(YYL- 01 t 30
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cr.
i
11* Permission is he eby granted to dispose of the human remains de ribedavp.,4_cated.
Date Issued 6 Registrar of Vital Statistics
(signature)
District Number S6of Place 67e s, ,&/f//Ty /d C
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z ii
1 Place of DispositionW
#� Date of Disposition 9 Olt Pi,* 9e-J �ov.e(Vi'w+�
ill
(address)
in
it (section) (lot number) a (grave number)
iC Name of Sexton or Per n in Charge f Premises t t(1s� e ^-e
Z lease print)
Signature G (IL — Title ctepir iq,
(over)
DOH-1555 (02/2004)