Pitman, Richard NEW YORK STATE DEPARTMENT OF HEAL-i� 1 �1(
Vital Records Section Burial - Transit Permit
`' Name First Middle Last Sex
�Lt-�ra�C) 4_1. Q�T rr AN \
<; Date of Death /5/ Age I If Veteran of U.S. Armed Forces,
( IC
; War or Dates 1 4.V y vr31_►ao—'P
.....
Place of Death f� Hospital, Institution or
City, Town or Village�(,L�S cP+s-S ! Street Address C L_ . t-s FAL_ 3 1405 S ITA c--
is Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined ri Pending
Circumstances Investigation741
lii Medical Certifier Name ` Title
a I <.1•- A L M€ 1 11.E s M
$< Address
`.. hC. ' C 5T G L_E Iv S -FA t__.s P. ) `1 l ado)
<::3 Death Certificate Filed / District Number fiegister Numb /
iiii City, Town or Village °LL PS FA try--S 1 c(-,O 1
Date // / I C metery or Cremator
�` ❑Burial A [ is _ f �� t-'o \) ►E,J ( a V‘'7 ALTO L'
�i Address
in Cremation ��A.k t✓ 2 Zo 0.--9 Qv cc.i,,sgv2y, 1 w
�\
Date ` Place Removed
2❑Removal and/or Held
-- and/or -- — -- ---
r i Address
Hold
Date -- _ -------- _—Point of _El Transportation Transportation i _ j Shipment
a by Common Destination
Carrier _
Disinterment Date ( Cemetery Address
Reinterment Date Cemetery Address
-f', Permit Issued to Registration Number
Name of Funeral Home &titer Ft-wet-al norn ... Of 1 ��
'
> i Address As ll LcJc €tic � JQL/-. , (Ai cwsb ,�rj ; New 70rA- /
Name of Funeral Firm Making Disposition or to Whom
`_`""• Remains are Shipped, If Other than Above
44 Address
fry
$44 ---
iiil Permission is hereby/granted to dispose of the human rains cribed above asijndicat
iiiia
Date issued 0 D /0O/� Registrar of Vital Statistics `�,,� �i�'/si,, p9/---‹
"'i / (sign ure)
IN District Number ,..5-6,6/ Place
l _�� !
I certify that the remains of the decedent identified above were disposed of in accordar4with this permit on:
6 Date of Disposition C/9/IS Place of Disposition e4161 C✓r —
2 (address)
111
th
£C (section) A(lot•numb (grave number)
G Name of Sexton or Person in Charge of Premises !�IL
r,
g (� (please print)
W Signature Title firrir+p i-
(over)
DOH-1555 (9/98)