Rawson Sr, Winslow I f73
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Nam First Mile Last Sex
,3 t nS l ou) 0, Kci t,t.)son SR . ti1a)e _
Date of Death Age If Veteran of U.S. Armed Forces,
03- 0 1-2-D 15 .34' War or Dates 1j0
H ce of Death r Hospital, Instituf n pr J - i
W MD Town or Village l�I S t-a.113 Street Address b l i is I(5 _1 t O I
Lp Manner of Death J Natural Cause E Accident 0 Homicide Suicide 0 Undetermined Pending
Circumstances Investigation
W Medical Certifie Name Title
CI amr.► KKA 13 a P�1 b
" Address
Glens .1k Ny
i Death Certificate Filed Ca
�N District Number Register Nu ber
(Citi Town or Village bien3 t-G as 5001 /6z-
r ❑Burial Date C etery`oi Cremat ry
03 D9-201,5 `ri rle_ V i e � C ►"Yl
Ri re a 1-0. ly
di❑Entombment Address
Cremation
Date Pla a Removed
Z 0 Removal and/or Held
0 and/or
Address
N
Hold
0 Date Point of
Transportation Shipment
a by Common Destination
Carrier
AlDate Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
"
Name of Funeral Home mF tw r furuej'a J yr 111C 00341
1. Address c 4 n l►l w-ci S Lak.Q LtAz_ei"-vu /L'ggo
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
IL 0Permission is hereby granted to dispose of the human remains des r'bed a ve i dicated.
Date Issued Od f�4.01J Registrar of Vital Statistics ) I-
' ",, (signature)
District Number 3 O( Place e,�' li, `moo/
HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z i L 1 Place of Disposition -'^d �:..., .,_,LLI Date of Disposition � � s" p � �.+.+,,-(`
2 (address)
Cl)cu
w (section) (N. number) (grave number)
CIName of Sexton or Person in Charge of Premises i+ p
Z (pleas print)
W Signatures Title «="'A2
(over)
DOH-1555 (02/2004)