Benson, Rex NEW YORK STATE DEPARTMENT OF HEALTH /051
Vital Records Section , Burial - Transit Permit
>' Name First Middle 1 ast Sex AA
nex F f'..„)Cf/-7_,D�./ 7,1
iiii..iiii Date of Death Age If Veteran of U.S. Armed Forces,
O- /7 /S- 6-3 War or Dates t
Place of Death Hospital, Institution or
City, Town or Village Lq1 L vze/Z f7e Street Address /5 7 &:,.c/` GC i r e 2 DP\_‘
Manner of Death Natural Cause ❑Accident Homicide Suicide Undetermined Pending
evi
Circumstances Investigation
al Medical Certifier Name /' (-- Title
Address
(... 6 5/ g://72e/a 7:?-7 re_ e,,,,," yi. ,/),
........:
:::::
::::.•
:::::.....
Death Certificate Filed District Number Register Number
City, Town or Village ,C�/(�. z u z",7 e 570 4, /y
Date J Cemete�jor Crematory
❑Burial /6 -i q- /3 0' //7e V//PJ Cre mat `7LD/2)/
Address /
::::: Cremation 0 a-e-e-y7J U ary /V Y
Date Place Removed
❑Removal and/or Held
•
and/or Address
67 w Hold
O Date Point of
fti ❑Transportation Shipment
5 by Common Destination
Carrier
::: ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
11 P � ration Number
Name ofIssued Funeralto Home Da,"2
S�Gre ,�72e/C r V(� Regista ���
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Address -7 54.P Y/-)7,4,-/ Ave_ Orz.if- ' fl y /a r) . -
Ail Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
igii Permission is hereby granted to dispose of the human r m ins desc ed a o as indicate
irli Date Issued /U- /9- /$ Registrar of Vital Statistics L l` ! ..4,..0-4-Ge./1(-1—e---
(signature)
iiii
i]ii]ii District Number p iJ Place jab/
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition lOflQl/S Place of Disposition rµilt.d ( :«-
2 (address)
ILI
Cl)
CC (section) /(lot number.}.. (grave number)
GName of Sexton or Person in Char of Premises G hrA57L- `'•r11
g 7 (please print) t
L! Signature Title atElitla
(over)
DOH-1555 (9/98)