Havens, Robert NEW YORK STATE DEPARTMENT OF HEALTH
' " # b71
Vital Records Section Burial - Transit Permit
Name first Middle Last Sex
Koberf- Char 1es 1.1a.ti nS rna/�
Date of Death Age If Veteran of U.S. Armed Forces,
o f 13 I IS- 5 7 War or Dates
P e of Death Hospital, Institution or ++ii
r ity Town or Village G1e 6 _I 15 Street Address Gi lcr►5 re,I is ft0 S p i +x,(
W Manner of Death L. n ❑ ❑ ❑ Undetermined ❑ Pending
Natural Cause Accident Homicide Suicide
0 Circumstances Investigation
WCS Medical Certifier Name T fa A 50
c ( A 6 I jaTit ri I.
Address io2 Pe,lc: Sf,- ,.1.) 6-/r,,s rafts ,4/y
D ath Certificate Filed le n �a.�is
District Number ou 1 Register I�,�r
i Town or Village l�
Date Cemetery or Crematory `�
LI Burial (I / js 1 ! S t'pne Vie MJ Crernct1-0rr tit_r►‘
0 Entombment Address
g]Cremation Queen 56r4/1 i /I• y. /,2..Qa 4
Date Place Removed
z ❑ Removal and/or Held
and/or Address
H Hold
CO Date Point of
a. ❑Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
E Reinterment
Permit Issued to `r``��,, J�,��1 Registration Number
Name of Funeral Home CAIl IJ f `' 71. I'�Dng-
Address ( A fa fL S1 L'i �i� �N��d T2b35
Name of Funeral Fi_r►mt WiMaking Disposition or to Whom
1— Remains are Shipped, If Other than Above
M Address
CC
Permission is hereb granted to dispose of the human remains descr, d bo as ' icated.
Date Issued f57'XY5— Registrar of Vital Statistics
(signature)
District Number S&cy Place .7 j;/ , ft-Y
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tJl: Date of Disposition 1/11416 Place of Disposition .,IL> Lr ,or,Jr,✓
(address)
W
ce (section) L (lot number) (grave number)
0 Name of Sexton or Person in C arge of P emises (iir+, i.- �'eNweiT
(p ase print)
al Signature Title fILEW
(over)
DOH-1555 (02/2004)