Grugle, Robert NEW YORK STATE DEPARTMENT OF HEALTH 4 1
Vital Records Section Burial - Transit Permit
igig Name First Middle Last r `� Sex
r'�
R abe_ r
to Date of Death Age If Veteran of U.S.Armed Forces, U
_ &-13 !0Lo I 2.01, 5-0 War or Dates /J/A
• Place ath Hospital, Institution or
ifi City,q- Or Village Q UeAs1��- Street Address 1 Hei n r;c. C., c'C\t
a Manner of Death LA Natural Cause El Accident DI Homicide ❑Suicide ❑Undetermined ❑Pending
la Circumstances Investigation
ui Medical Certifier Name Title
RobeCA ,c2.rP M 0
Address
\ron ek Cian-w C G 1 f.NnS �o+\`S
Death Certificate Filed NumbRegister Number
iiiil City,Town or Village C eec.s j r ��ter C)
<==>j['Burial Date 03 IC7 laol* Cemetery or Crematory
1❑Fnimbment Address P i`n f' i e vJ e'e Q c
UCremation LQ per L£orvc\ouf-,1 12-201
Date Place( .Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier _
❑Disinterment Date Cemetery Address
.;::::;i`:❑`: Renterment Date Cemetery Address
:
Permit Issued to t Registration Number
Name of Funeral Home t" al nOt1 Ct 1, 0.kcr Fune cct! N omt of i l O
Address
11' La ave+-fie Sireet, Queensbu ry , Neon) Vor- c G $0(-1
lif Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
t
w
CL
Permission is,hereby granted to dispose of the human remains described above as indicated.
0Date Issued 1 bo(`f Registrar of Vital Statistics 5c-,_ 0 C)J n.=..
(signature)
iiiiiil
•• District Number, --) Place ef),c akss....iNSLJ-k___\I certify that the remains of the decedent identified above were disposed of in accc ti"` ` k e with this permit on:
la Date of Disposition <3/ioIIj Place of Disposition -�i t,r c....vidr:,_
(address)
11.1
fi
(section) (lot num (grave number)
Name of Sexton or Person' Charge of remises nl t+ r t
(Please Pint)
Signature 9- Title G1Zdr
rt
(over)
DOH-1555 (02/2004)