Hubert, Raymond NEW YORK STATE DEPARTMENT OF HEALTH ' it 33/
Vital Records Section lt Burial - Transit Pe'remit
-YN Name Fist Middle Last Sex
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4Age1 If Veteran of U.S.Armed Forces,
: of I.F Date VI CFj 1`t ) 201`(r 1
war or Dates r q57 - r q5q
Place . 1,. �,,y,�..�
.!1 ��.tliiJlN7 7 or
I Town Village PJ LAY 1 Strre�eitAAddress qZ \Nil M0-n. C CI
M •' •` ' Death Q Natural Cause ❑Accident ❑Homicide ❑Suicide p Undetermined 0 Pending
<= Oreut investigation
. Medical_ Certifier Name Gil;C P i 11 ern e� Title M D
Address I Do PotrYN a}c ee t- a 1e.1•114s FalN s, N y 12$0 1
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• Dea CitY�Vla Filed ageC \ok iWkict Number Register Number
Ii Btria l Date 0,5 1 1 et 1 7-01 Li CemPeteQ CX erM-,aNOrY
Address
Cremation I v_o,.Nhey-- (2_00.4 «.y-%Sb kr i N .1,
Date Place Removed
0 Removal and/or Held
M for Address
a Hold
Date Faint of
0 Transportation Shipment
by Common Destination
Carrier .
Q Disinterment Date ' Cemetery Address
Date Cemetery Address
Permit Issued to Name Funeral Home H tla.rd v 1 'Wer Funeral f 1om Registration Number
., Address
Y` 11 Lctfa.�.te#e c . ,br c e e,ns�bu�-cj,Al Yoc,k l a 8vy
Name of Funeral Finn Making Disposition or to Whom
�. Remains are Shipped, If Other than Above
I Address
Permission is hereby granted to dispose of the human TeTains described as indicated.
'_ Date Issue )tc Imo)[ Registrar of Vital Statistics ,-4 , 4-(.--�
( ^e) l
cc9 Place / 6 4 S L. u -r sFm�
District Numbed ��� t%�
I certify that the remains of the decedent identified above were disposed of in.accor ith this permit on:
f` �7
5 Date of Disposition 6-20-ill Place of Disposition 'I nd/p�
_C" ct:.
a (address)
to
(section) / (Jot numl ar) (grave number)
Name of Sexton or Person' es L {Charge of Premises
,t J L'n1 I
(please print)
Signature / J. Title aFii rl I
(over)
DOH-1555 (9/98)