Slawson, Robert NEW YORK STATE DEPARTMENT OF HEALTi n 36
Vital Records Section Burial - Transit Permit
Name First \ � i fiddle t�L�a�stC Sn
Date of Death Age j C If Veteran of U.S. Armed Forces,
i 9 '--\ Lp J War or Dates
Place of Death Hospital, Institution or Clkd
i City,Town e \cr1 ti\ Street Address J 3 v1 �OR r ►v`i
a Manner of Death® D Natural Cause Acc' nt 0 Homicide 0 Suicide Undetermined Pending
111tri
Circumstances Investigation
Medical Certifier Named \ Title
c\�c .'`(lSA s`•-)k 63Y sic ?3-Ni-Np M t a t
iio Death Certificate Filed Dist ' t Numb( �` Register Number
Town oT 'itlage v '1 c,
Date ,,metery or Crematory
riq�Buria! /
=OEntombment �152 ' a3-\� , ktVv �Q�.'J �/ ..(�Q"-6'�
Address
P �\
•174Cremation V
Date Place Removed
2 ri Removal and/or Held
and/or Address
rz Hold
0
Q Date Point of
co Q Transportation Shipment
a by Common Destination
Carrier
' Date Cemetery Address
Q Disinterment
0 Reinterment
Date Cemetery Address
11,
Permit Issued to � Srnb r Kj its \.\\c,c\Ns‘
Reistratn.Nurryber
Name of Funeral Home t
lik 11,-, , \)`s.(aiN`CNOOtk`C\ ksk,Address )6 1A r \ N\f -�•
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
IZ
Permission is hereby granted to dispose of the human re ins describ d above as indicated.
Date Issuedaq-a^\ Registrar of Vital Statistics S`. Cj-,- V.j'" "
(signa re)
�
District Number y Place ,.,,^r I certifythat the remains of the decedent identified above w re ' posed of in accordance with this permit on:
l 2 i -41 1
L� Date of Disposition�"��fi Place of Disposition / rv,�,�/,�,-,/
(address)
W.
(section) /J (lot number) ' (grave number)
IPerso Charge of Premises `` � " �(1.� "`//(/3�'r C
Name of Sexton •
(p/easye p iini) l
t Signature v Title `-���i''1le '"`) T
(over)
DOH-1555 (02/2004)