Russell, Matthew it S3
NEW YORK STATE DEPARTMENT OF HEALTH f kt)
Vital Records Section Burial - Transit Permit
t >r , `l`
. , Name First 1'\ Middle Last �,uSSe�� 1 Sex
< : wA- 2uJ v;0�Coon j
Date of Death i Age i If Veteran of U.S. Armed Forces,
05 1 2,2- \.ZO y 5 War or Dates IVO
Place • •-ath Hospital, Institution or
City, own .r Village eerC r-
Qu Street Address 3 lO ,\C 6 �Oz''rh
Manner o Death❑Natural Cause D Accident n Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
O Luz __.hequft, -- r1
Add;: Address
_ 128.3�
1''�_cam 5A-. off_�al\s l�
;:K:. Death rtrficate Filed District Number � Register Number
City, r Village C \S 3L.r1 "(a5'l i l�(e
Date t ; Cemetery or Crematory
Burial 05\ aJ 1 Z C>t Pi- v1 e_ V t.�3 -r `/
Address y -I
Address
I�.Cremation f � t Q v
1 C cA . �,.R sb".. 1Jy 1 2_80�► —i
Date Place Removed
O❑Removal and/or +-!eid
andlor
t;.: Address
Hold
VN a
O ! Date , ?U,nt of
NJ Transportation Shipment
Ei by Common Destination
Carrier
E Disinterment Date Cemetery Address
Reinterment i Date Cemetery Address
•
Permit Issued to ( , - Registration Number
Name of Funeral Home/�-1Gt��/�a IC/ 6 Baiter f-c-.cne1al Hams i CI 1 30 —
Address
11 Lara-y t#C . , ( c.tt-L,nsicarci , /Ciew tjork l KY/ --
'>> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
MI Permission is hereby granted to dispose of the human re . s descr • - • ab indicated.
Date Issued l 'It)_ �014 Registrar of Vital Statistics 4,Li` A
'_ / (signature}
District Number 5101 Place 1 0 ,,,y - dab ••— s
vr
I certify that the remains of the decedent identified abo - were disposed of in accord-
ith this permit on:
f- '2
iii Date of Disposition S- ii4 Place of Disposition 6:14-c(oP _ 4�4
2 (address)
iu
tl3
CC (section) (lo um6er) (grave number)
GName of Sexton or Person Charge of Premises �°"' ,iwr
Z (please print)
• Signature t. ATitle CrtifikuRt I
(over)
DOH-1555 (9/98)