Vitch, Robert i
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
NPe . First Middle r _ Last Sex
t ,v icn, Ma le,
Date of Death A e If Veteran of U.S. Armed Forces,
LkI -'�I `I- War or Dates
P .ce of Death I ^ Hospital, Institution �r� �_
ILITown or Village I 15 o Street Address G Ik;6`1 S i.i5 i}rd
0 Manner of Death El Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
ILI
0.
Circumstances Investigation
tu Medical Certifierp N me Title
n k.X.kC►'\NLc 1 M b
Address
l Q,rT sbc ,\rV
ath Certificate Filed District Number Regi ber
Ci , Town or Village G l s 1, <500 I,
Dat C ete or Crematorpd-
����-'l 0"1
'" ['Entombment
1 ' �' f
AddressG� J
�jCremation G, { )1
Date .J Place Removed
Z Removal and/or Held
2 ❑and/or
I.::: Address
Cl)
Hold
O Date Point of
gri❑Transportation Shipment
G by Common Destination
mi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1\-11 1 11 @,f-- "h,crua.ry I _ nuclei
Address (_0357 'lam K-tA I V.VC Y\ L o- V (2ALIL
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
s Address
It
U
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued U /-Zt / /C/ Registrar of Vital Statistics w C.A-A - Q
(signatu )
District Number 5 ,d( Place ' 6 f_ 5, ll5 IN
I certify that the remains of the decedent identified above t�'x were disposed of in accordance with this permit on:
tii Date of Disposition ithtllti Place of Disposition entityet-Jima...*
2 (address)
CLI
CC (section) (lot nu r) (grave number)
Q
Name of Sexton or Person in harge of Premises Littio- gli
/ (please print)
Signature �<.ill
Title (6).Wire
(over)
DOH-1555 (02/2004)