Bossert, Richard ,. • . , f cig
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
pr Name First d-7) Middle , Last Sex m
T\kahar tiv t expssert
Date of Death i I I Age If Veteran of U.S. Armed Forces,
1q5CHCIU)2-
1 War or Dates
•1,;.!,'''''. Place of Death Hospital, Institution or
Z - own Li4lee OLK_CLQ...111-JLA.A.I..)6-- Street Address ci‘see-slic ---,
1c6 L.-)hvc-v-c-t PL 1,),I. t -iscei
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Manner of Dea
?.154._Natural Cause u Accident n Homicide El Suicide ri Undetermined 0 Pending
11;1 'Circumstances Investigation
u9 Medical Certifier Name , , ,• Title
IP N 11 11 ett-Y\ ex:90s IA,0
W Address
EMi: 1 CS) 1 Careti--- RA_ , Ou,sux-mbLkAtA KN i 2,70Y
Iiv Death Certificate Filed ,,..,&KX) I'D(...Alk_t_j U District Number s --4. 1 ReXter Number
ii.O.: entr, 4M: • ..e U _CLQ
Date Cemeteryc<=ato-1
remryM--m-
." 71 2119115 t' N...,-•,--
.:.: 1_1Burial
Cremation' Address
• 0-
) L-4
Date i Place Removed
gri Removal and/or Heid
;IT 'and/or Address
4= Hold
0 Date T. - , -
: CAM OT
05 0 Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
::: 0 Disinterment
Date Cemetery Address
:::: 0 Reinterment :
.....
Permit Issued to Registration Number
Name of Funeral Home Hayna frill &tAer Fc-u-iercd name_ Cl ' c,--,
Address
1 1 I LOr a-v ette (3 . , C4c_c_c_nbt,tr z d , Ala() 90 r)c_ I,2 YO1
Name of Funeral Firm Making Disposition or to Whom
44 Remains are Shipped, If Other than Above
41V Address
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tu.
Permission is hereb granted to dispose of the huma -r- nains described above as indicated.
„.„.
-....
Date Issued 0C Registrar of Vital StatisticThCN._
— -----. (signa re)
a
A District Number
Place i
I certify that the remains of the decedent identified above were disposed of in accorda e with is permit on:
f.-
EDate of Disposition 2/16/IS Place of Disposition elt 44•4 i\--
2 (address)
ILI
W
CC (section) 4(lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises tzth,iriy-1- J J.
0
Z
efil.i • ./1...._ (please print)
.44 Signature Title (12,1244)rk_
(over)
DOH-1555 (9/98)