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Roth, Donald NEW YORK STATE DEPARTMENT OF HEALTH t -- lk It L? I Vital Records Section ' Burial Transit Permit rig Name First Middle Last Sex ,IN At-0 \.\J=1.�.t tkvrr\ 1ZCDTK M iiii Date of Death ' Agnot I If Veteran of U.S. Armed Forces, Si l©I ag I a Q►,{ I War or Dates — ��41 Place of Death Hospital, Institution or City, Town or Village au r.= r�5 c>�9_,-t Street Address 11- J o w *i 5-f Manner of Death rviNatural Cause 0 Accident b Homicide 0 Suicide EiUndetermined ri Pending Circumstances Investigation_ Medical Certifier Name Title 9 ac* - (5TcxsrE+s%v,kt, NO •i3. Y" (�LC�S V A�.1.s , p � la$ Address .,, .t_. loa PARS �, �:E,; d iiiiKi''i(' Death Certificate Filed District Number Register Number 1.i.0i, City, Town or Village 5(o 5-7 I gq Date I Cemetery or Crematory ❑Burial 10 / ' ) ao1 4 4" i b r v _E� c Re 01 vto tZy Address `i Cremation Q i 4.ua i?..©KO (�vLI:t r�s C vQ`, , tJt. ta8o4 Date 1 Place Removed 2 Removal I and/or Held . and/or Address --- Hold n Date -- — — -1-P Point of N0 Transportation j Shipment Q by Common Destination Carrier ::::: Disinterment Date Cemetery Address Ej Reinterment Date Cemetery Address giig Permit Issued to ,� ` / I JOm� j Registration Number << Name of Funeral Home 1;moo-Hard b, Zaker Fw1ercL 1 Of I �o .::::::- II Address ` i/ Lr{ayettc c . , 0Litf-CDSbarC j r /J `J0r) I, e0 Name of Funeral Firm Making Disposition or to Whom ..'" Remains are Shipped, if Other than Above 44 Address A ::§iii, Permission is hereby granted to dispose of the hums ren s'descr`., b• ,e as indicated. ? l Date Issued 10-X)-14 Registrar of Vital Statistics i// :x3 ,43 nature) gi" District Number 5r;Q`j Place k.b n_ (D ,p ,,,p I certify that the remains of the decedent identified abo were disposed of in ac rda a with this permit on: 5 Date of Disposition /b tab(piPlace of Disposition 1,4, 14-1 (,rra= ,.-- 2 (address) LLJ an Glr (section) (l number)(' (grave number) Name of Sexton or Person in Charge of Premises Ir;.4'q. 1�"'� Z (please print) 1 W Signature /"� Title C'//�;4J pp- (over) DOH-1555 (9/98)