Ryan, Robert (2) NEW YORK STATE DEPARTMENT OF HEALTH * it 7(,g
Vital Records Section Burial - Transit Permit
Name :-First Middle Last ex
Date of Deat Age If Veteran of U.S. Armed Forces,
ic1— L'JD 14 (04 War or Dates 1\)1 p
}- Place_voL4eath Hospital, Institution o f
CityILI , Tow r Village -load k�J Street Address ` l rdI >`L�1�
a Manner of Death Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
IA Circumstances Investigation
tij Medical Certifier Name Title
P /*m John 2 aI/ PA-
Address
0,0r I n\--h Ny
Death_Certificate Filed District Number Register Number
Tow City, ner Village {-,actteL 1
❑Burial Date Val etery or remato
❑Entombment , ! ' Y1 rema 2r.4'1�1 atn ii _j
Addr s
►'I,Cremation u t l b u_A-u NTV
Date Place Removed
Removal and/or Held
2 and/or Address
Tr.1.7 Hold
01
01 Date Point of
fL Transportation Shipment
tl#
ta by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home -b`('e't l.'"GC 4 l n(--- 00a 1 1
Address
o4 0 irmych -'t Lakk, L*7--u-ru c\l / L63/1r
/
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t•L
AL
Permission is hereby granted to dispose of the human ns described above as indicated.
Date Issued `a-`�j- 201 Registrar of Vital Statisti ,,� kY!q i:�
(signature)
rNeArfr
District Number Place )p I�
I certify that the remains of the decedent identified above were di os d of in accordance with this permit on:
Z
al Date of Disposition/-M 1/Place of Disposition r!Y'k Vs<qi
2 (address)
1.11
CC (section) 5--a ...# 4t1ber) cd (grave number)
p Name of Sext r r in gharge of Premises h,
(p/e/print)
tt Signature / Title0A 4-i'
(over)
DOH-1555 (02/2004)