Miller, Robert NEW YORK STATE DEPARTMENT OF HEALTH ` C
Vital Records Section Burial - Transit Permit
Name First Middle A.:1 / Last Se) ,4
Date of Death i Age If Veteran of U.S. Armed Forces,
Co/3 ` Roil ty War or Dates
i..., Place of Death Hospital, Institution or
W City. Town la e Ca f`'i\---t-t.., Street Address o2o1 i/ S7
Manner of De4e Natural Cause Accident 0 Homicide 0 Suicide Undq(ermined �Pending
W Circumstances Investigation
W Medical Certifier 21 (/\NamewK
} 1 Title
r+� , [.�ie.i 40
Addre
s �ar( i.--.4"e Sri P., , N. /. 14)166
Death Certificate lied .__. District tYlrtmber a S Register Number
City. Town Ila e �r�'
ate Cemetery or Cremator
._ Burial 7/1 f aolt ;4cv:c- 6eA".4.4ar
Address
NT Cremation 6.)2,..k.d_e, b,,,3 i 1ue ... rr�
Date Place Removed
Z Removal and/or Held
• `" and/or Address
(n Hold
O Date --Point of
5 Transportation , Shipment
E. by Common Destination
Carrier
Disinterment Date Cemetery Address
—Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Ho .A Sru-,re- -I;",,r., ( 4...t� ,j, vo r.��-1,�/
Address Jtt.rM•_ 4v� 6^z-+ - P. i I $d'
•-: Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above ,
•
Address
rc
Permission is hereby ranted to dispose of the human r a ns scribed ov -s ' •icated.
Date Issued / y Registrar of Vital Statistics 444 1
• a re)
District Number ii ) Place �� r'` -/ /l/c,.-' y�r�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition "7-2'1,11 Place of Disposition ',.ak..) C,...J, __
g (address) -
w
CC (section) Lii).,
lot number) (grave number)
• Name of Sexton or Person i Charge of Premises nwb}-
Z (please print)
41 Signature Title Cf/iliftrite
DOH-1555 (10/89) p. 1 of 2 VS-61