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MacDonald, Jr. Raymond
f- - , 1275 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ``f1 Name First Middle Last Sex RA/fY\t)19 - Ul `Th R c- et•t A t_9 1-Iz, ALE Date of Death Age If Veteran of U.S. Ar e orces, 3 ra011 (0 3 War or Dates IR_ A 44 Place Bath ) l O1 ( Hospital Institution 4-City, Town or Village Street Address 1.4 g VPP�R QBELL LAKE Manner of Death a Natural Cause ❑Accident ❑Homicide Suicide Undetermined ElPending Circumstances Investigation Medical Certifier Name Title Address 3161 —11-\1\9. "y •-t-, Lo Ac sB(Rt&G 1 1 & - Death Certificate Filed -Distract Number Register Number , Town er--Wiage- LAkE OVZGf, (5/ .3 Date • err-er Crematory :: ❑Burial aS) Jon Vt IAF: U 1 E t.t-) CRET(Ni\—VC*IILYV . Address :: TgCremation J\ CR u i\KEK i-9. �fl EE11.S eu i� A ) 01 -0�- Date . Place Re�nov .d 0❑Removal and/or Held ••. and/or Address Hold Date Point of Q Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment ' Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home >V i✓( 1 -1-k-cvnC= / M.C 1 01 (0 4-9 <i Address L.0 `A(`t\©I0-1-6 U(11� -ST L-A ' . c`�4c-C - `1) ) r� $1`1',s, Name of Funeral Firm Making Disposition or to Wham Remains are Shipped, If Other th,1: Above Address W Cti pii Permission is hereby granted to dispose of the human rem described above as indica ed. iREgi Date Issued 5p f,/1 J f Registrar of Vital Statistics (s n ture iiK District Number 5 S/ Place I certify that the remains of the decedent identified above were disposed of in acc dance with this permit on: f- Q tuDate of Disposition �"l(,-k( Place of Disposition '1 xut,)‘i0.) Cr` 'fct iV` i (address) LU (/) CC (section) / 1 (lot nurer) (grave number) GName of Sexton or Person in harge of Premises I Wa}-cT .",off g a (please print) W Signature Title CP) a., DOH-1555 (10/89) p. 1 of 2 • VS-61