Robinson, Eleanor It zO 2,
NEW YORK STATE DEPARTMENT OF HEALTH 410` "1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
f t e-A is 6�. 1'us tAt`-L �'�nB i,Jsr)�3
Dat of:Death Age If Veteran of U.S. Armed Forces,
11(6 /aOlS 91 War or Dates .,J ..)-
J: Place of Death Hospital, Institution or
Ca CaCity, Town or Village E7w r,�� Street Address \t `- .sa \ &i N v ���+ V,
Foy Manner of Death Undetermined Pending
Circumstances Investigation
ul Medical Certifier NAm,e Title
Address
Death Certificate Filed District Number R"egi eyi N�umber
<>] City, Town or Village V�,— 7 v A f) .5 R-S 3--
CD
.ElBurial Date ) Q� / Cemetery or Crematory
❑Entombment 3 / I C� / a� S el tv c_ v 1 E. L.J ct�E 1M 4-1-0 SZ`-)
Address
Cremation Qv A vi-ccl_- Znt,7 OLL t,3S i2.3v -_`-\ )`' t P-g O t-1
Date Place Removed
Removal ' and/or Held
and/orHold Address
C Date Point of
E Transportation Shipment
f by Common Destination
iiiiiiii Carrier
` Q Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home tq h'i IVA 2;-) D. NP lax V-01,3 L-(t AL_ 6 \. 'S O
: Address
[ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2. Address
i
111
IZ
Permission is ere y granted to dispose of the human re described abov as i icated.
iiiiiiiiii Date Issued 1 'S Registrar of Vital Statistics ( /
(signature)
.-�^ ¢
District Number Si B5 Place -L L 11.1a4.0(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
111 Date of Disposition 3(I!�ir Place of Disposition _ihr
a (address)
til
w
1 (section) //J�ot number)( (grave number)
Ct
Name of Sexton or Person in Charg f Premises G��°3 '-
' (plee' print)
14
Signature Title CIZ'9'=i'4177U
(over)
DOH-1555 (02/2004)