Hayes, Robert NEW YORK STATE DEPARTMENT OF HEALTH it 31
Burial Vital Records Section Transit Permit
in Name First Middle Last L\�� S Sex a A
sober rI �"\
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« Date of Death Age If Veteran of U.S. Armed Forces,
8 \1 Zy 1 Zp t5 CO I,p ' War or Dates NJ I
` Place of Death Hospital, Institution or n
Ci , owr or Village NJ cxrrenS\Dor� Street Address 3I burC����L 1'T1 e
Manner of Death Natural Cause accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
°: Medical Certifier Name a Title , ` ,--
'"" Address
1035tL) N 1 U % \r-,d;on La tk, IQ` 1 2_814
>< Death rficate Filed District Number Register Number
Cityr Village Filed.
emetery or Crematory
❑Burial \\ \2 5 \ LoV e‘,3 Ccerno.Vbc
Address
i IX1 Cremation S,0 , p awl �r\L .
g Date T Place eemmbvved
. 0 Removal and/or Held
•.• and/or Address
.171-7 Hold
O Date ! Point of •
ai Q Transportation. Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iM Permit Issued to _ _ / Registration Number
Name of Funeral Home _ _ . , i4K6- 1"-CJ,J A , l'7t�NL O/J 39__
Address /
gi it C. 3 it.-_,--- ¶ . U as a v r� r J /2..�v y
Name of Funeral Fie Making Disposition or to Whom •
Remains are Shipped, If Other than Above
aAddress '
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Permission is her by g anted to dispose of the human re _ ins dee ribedib above as indicated.
Date Issued /// S,- /S�Registrar of Vital Static IC, 'L 4 ��..-----.
(signature)
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District Number 6 v Place !�1 ffe-41S 6 u /),/r /2 K ��
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition II It?gl( Place of Disposition /ImtVl.-1 ('"'*"-'
2 (address)
iU
U)
C (section) �Alot numb ) (grave number) •
GName of Sexton or Person -in Charge o Premises 1itr,
A . (please print) V
>. Signature Pt Title (welt
(over)
DOH-1555 (9/98)