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Millis, Robert NEW YORK STATE DEPARTMENT OF HEALTH, 41 51 I Vital Records Section Burial - Transit Permit Name First 1 Middle J Last s— Sex Date of Death Age If Veteran of U.S. Armed Forces, ii/' �, fka►� Z3 War or Dates -- Place �e th Hospital. Institution or _ Z Cit , T wn o Village ra r ; J Street Address S ©g`t 9 N AMan er a Death Natural Cause 0 Accident Di-lomicide D Suicide Undetermined Pending IliCircumstances Investigation W Medical Certifier Nam + Title L) Address ,11 6,— r S • 6,,c - /U 1 ( ?) — Death f ate Filed district Number . Register Number Cit , T wJr or)✓illage r', A--a, ! 5- _ Date Cemetely or Cremator ._Burial ti / 'Xi 4°1\ I Acli:c.,., 6,^^14r Address p � ((( Qj .Cremation Cor;• _ 1 Vew *i'(_ ) Date Place Removed Z — Removal and/or Held • —and/or Address N Hold O Date Point of flh 0 Transportation Shipment Q by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Ho�S . r-c �—.te_r,( 14,4c/ _Lc- - 00,4-i-g Address 7 tl e!"Ac-- 4v e-� r:'A.t� Ni V ?�- Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped, If Other than Above 2 Address IL Lti Permission is hereby granted to dispose of the human r ains scribed ov s ' icated. Date Issued (l / t /1 Registrar of Vital Statistics a re) District Number S3 Place 6,6, ) /� / Or I certify that the remains of the decedent identified above were disposed of in accordance wit this permit on: RA 1)�v Cw Date of Disposition �� Zi t'tb A Place of Disposition 6f+').a. 2 (address) t1.1 CC (section) / (lot number) (grave number) O Name of Sexton or Pers in Charge ofi,Premises L ()st �h-e1t 0 Z (p print) tint) W Signature Title CeenkItYL DOH-1555 (10/89) p. 1 of 2 VS-61