Hill Jr, Royce NEW YORK STATE DEPARTMENT OF HEALTH'"• 1
Vital Records Section Burial - Transit Permit
Name Firs dle st >� � L�f
Ve'..e' / YDat Death// Age y If Veteran of U.S. Armed Forces,
La t c I i c3/ A Ca/r / War or Dates
I- lac- • :-,th ry Hospital, Institution r/ //�� �
W Ci I,, Town pr Village l A,C '7/-trl Street Address / 6//j�Jci -—)/ ///�e''
a Ma, er . Death f'I Natural Cause 0 Accident 0 Homicide Suicide Undetermined 0 Pending
uitU Circumstances Investigation
Medical Certifier N e -e//ia7"I e-(. Title
ss (-(-e- (:-S' -C ,�
.,, i-V4%)-ee")
Death to Filed / District Number Register Number
City, ow Village (��{ ', �-c' `• j �' a-
OBurial Date 2 � or Cre attpry,�
['Entombment Addr��1 /P /` d L`.�c . - �GJ�1�1�1 ‘z C'/!`v'� s
ss A[Cremation L 1f .- .�/7 /)-- C' 4
Date lace Removed
Removal and/or Held
2 ❑and/or Address
Hold
to
0 Date Point of
Transportation❑ P Shipment
al by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to T \
Registration Number
Name of Funeral Hom j
C ^JG v>( 6 �` // "L ia3,�Q
Address h /f
Name of Fun ra Firm Making Disposition or to Whom /
Remains are Shipped, If Other than Above
2 Address
ILI
Ct
s` Permission is hereby granted to dispose of the human r A •escri771
as in icated.
Date Issued 4 I i /t1oiJJ Registrar of Vital Statistics /���� , '/v
j� h /y ure)
District Number j(og G Place--�2 t (2
I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on:
Iii Z o �4
Date of Disposition 'I- 1-1:5" Place of Disposition �t/ncUtv..0 6+,o_----
(address)
VI
Irk (section) j (lot number). (grave number)
Name of Sexton or Person in Charge of Premises a" t
2 lekse p )
Signature Title (OM '
(over)
DOH-1555 (02/2004)