LaVergne Sr, Robert NEW YORK STATE DEPARTMENT OF HEALTH ` 4 (S 7
Vital Records Section Burial - Transit Permit
NamOrs�t xt Middle �, f Last Sex
v trail SR. Ma 1e
Date of eat Age If Veteran of .S. A4rmed Forces,
( � apt + 7 War or Dates N)p
:- ce o DeathHospital, Institute nor �
Ci Town or Village G►ens Fa l lS Street Address (7)e Ia 115 amp iitt
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0 Manner of Death❑Natural Cause 11 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
US Circumstances Investigation
:W Medical Certjfitz., Name Title
tmo`�-It1 Mu r h C.orov
Addrbss Y
C�lute l c «s, Ny
Death C rtificate Filed District Number Register Number
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City, Town or Village G I 5 ki/Ls c560 I "'77
❑Burial Date Cemetery Hof CrematAry
❑Entombment l D- 17 - ,14- -pin U I el() rn.Gt�n
Addres
Cremation tlUg-e-nShn
Date Race Removed
Z Removal and/or Held
C ❑and/or Address
F_- Hold
0 Date Point of
LL El Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to n ^ Registration Number
Name of Funeral Home i�/t t I kr 'jypx' +- VW t) I I 'q
Address
pD (fox l l $ I n d l aan La p_I Aly I2fr
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Z
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` Permission is hereby granted to dispose of the human itnains escribedCbove as in• cated
Date Issued jd • Q/ Registrar of Vital Statistics 4, C-t7, `_ -
signatu e)
District Number 60 i Place -Z
if; J
I certify that the remains of the decedent identified above were disposed of in accordance with th. permit on:
lif Date of Disposition 10 I /obi Place of Disposition4;24(Lk.) 6,4. :,-
2 (address)
LU
tifl
IX (section) d (lot number (grave number)
Name of Sexton or Pers n in Charge of Premises /.31 Joe*
Z (please print)
iLl
Si nature I L Title ��y
9
(over)
DOH-1555 (02/2004)