Madison, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - Burial - Transit Permit
Name First q
.. Mid�+in /1 La t S• Sex 4,�
Date of Death Age If Veteran of U.S. Armed Forces,
7/ 6 / a o I '7? War or Dates ) 1 S`f--C- 7
i-/��of Death i � Hospital, Institution or U /
:.. own or Village `tf l-t�' Street Address �A. He
asp
v anner of Death Natural Caus Ac dent Homicide Suicide Un ermined r� Pending
US Circumstances Investigation
w Medical Certifier Na e IN:44. e,,, ,a.,,,,,
/ Title
Ao
A ess
1 C i urn ` ,c6i fk- f4f. m 7
e h Certificate Filed J District Ndtnbef Register Number
City, own or Village �A.rt--' ' p
Burial Date Ceme or Crematory
❑Entombment /T / YO i� i vt-c o ti L�
Address
Cremation N Gc,�S r
Date 1 l Place Removed
❑Removal and/or Held
and/or Address
w" Hold
0 Date Point of
1.1440 Transportation Shipment
O by Common Destination
Carrier -
❑Disinterment Date Cemetery Address
:: ❑Reinterment Date Cemetery Address
Permit Issued to Regist vign Number
Name of Funeral Hom �n 5M� am. �--r {-f `TT ff
Address /
,S1 er.4, y l
iliN Name of Funeral Firm Making Disposition or o Wh6m
1.0 Remains are Shipped, If Other than Above
a Address
ilk
UI
Permission is here y granted to dispose of the human rem ' es ibeda�ove as indicated.
iipii Date Issued j / S�Registrar of Vital Statistics f .
(signature)
District Number 1 f ca Place �G, ram , S Al 7-
I certify that the remains of the decedent identified above were' isp ed of�ordance with this permit on:
k lif Date of Disposition i/ (l r Place of Disposition fat C 1/�
's1dr•,•i
(address)
ILL
to
cc (section) /j(lot number) (grave number)
0 Name of Sexton or Pers n in Charge of Premises `�It.
« (p ase print)
W.
Signature ' Title (vowel
(over)
DOH-1555 (02/2004)