Losaw, Roger , it l
NEW YORK STATE DEPARTMENT OF HEALTH ' �1L
Vital Records Section Burial - Transit Permit
=7= Name First Middle Last ! Sex 1
9,pgC.v^ Sase 9`n L-c&.w M �
Date of Death �1 I Age 1 If Veteran of U.S. Armed Forces,
Oil 0621 14- 61 War or Dates 1\10
P ace of Death Hospital. Institution or
Ci Town or Village C\ens Via.\\S i Street Address G\•e S "Fa\\S i 40.
Manner of Death Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
W8 Address
_<: Iop Parma S �1� _ rA..\\,S I ') Izg D )
Death Certificate Filed , District Number Regist ber —
>'c Town or Village - \erS cA\\S J6p0 �
Date 1 Cemetery or Crematory
❑Burial 01 \ o i -2--6)
Per t \J a e\33 C(errNa•�-c,r I --_---�
Address
®Cremation (� ,, CI,L Y" S rt N 1
Date Place Removed -
Z❑Removal : and/or Held
and/or Address
N Hold
' Date ; Puint of
N❑Transportation i Shipment
a by Common Destination
Carrier
I:Disinterment Date Cemetery Address
❑Reinterment i Date Cemetery Address
iiig Permit Issued to ' Registration Number
41 Name of Funeral Home/VCtc fla(CI 6� taker FL-Literal //arn
C1 ) 3
Address l i L ar l L J
/Etc . , � �� s bur , /vew U��. 1 ecy l
g Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above
Ate Address
— — — I
Ai—
N sx: Permission is hereby granted to dispose of the human r mains de ribed abo e as indi -tad.
>z:'. Date Issued "7h/it/ Registrar of Vital Statistics _ Are / , Aar.. _/,► / _
>s . (sig t e)
1 District Number / Place atv2SAVIS; oZ(91-0/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZDate of Disposition )-`�-(4 Place of Disposition gig., (L nu,
2 (address)
Co
>z (section) ,1(lot number) (grave number)
0 Name of Sexton or Person incharge of Premises nil —
(please print)
Signature /�— Title 6244,
over)
DOH-1555 (9/98)