Carroll, Robert NEW YORK STATE DEPARTMENT OF HEALTH 11. if 60-)
Vital Records Section Burial - Transit Permit
Name First Midi Last Sex
lZc� e��- E . Carta 1 t M
Date of Death Age 1 If Veteran of U.S. Armed Forces, _
<v `1,
Q ci - Z Z• 2L)11I , _ g War or Dates )Ck 5- I ci'I�Q
'- Place of Death Hospital. Institution or
City, Town • Fb,(-r E v.�0,Y C� Street Address M C C•C e c S� '
Manner of Death �� Natural Cause Accident U Homicide [�Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name - Title
�_Chcie� �- \\r?r t'M 1�
Address
Death Certificate �( Distnct m Regis Number
City, Town FO✓')-- E C.CU`aYC` rl 5
LI-
Date n Cemetery or Crematory
❑Burial C l q 2 J �) ___1_ Pi n e U;e ki3 C1'-e m a+n&(y -_—I
Address
:::: [Cremation _IQ -f)Z )CD ,_- -t--t )-
Dateplace Removed �-
x❑Removal and/or Held
and/or Address
Hold ---------�_._ __
j Date T Point of 1
Sip Transportation j Shipment
a by Common Destination
Carrier _
Disinterment
Date I Cemetery Address
El Reintemtient Date i Cemetery Address
Permit Issued to Registration Number
r,,,:. Name of Funeral Home M rci b, Baker Feral hOMe- 01 ) 30
Address
/I Lafa-gdte . , bwe.Frxburcd , juao %ak- l a'Oy
:-` Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
" Address
':u
IfPermission is��hereb granted to dispose of the hum r aims described ve indicated.
ADate Issued //"1 c -`t ` Registrar of Vital Statistics Y `
i:o. (sig re all-ell
�"�' District Number Place - °
5:12-4I Ozc7n
YY.^'.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fi.- �
fgii Date of Disposition 9)30(/4 Place of Disposition __.__�1_ atv C r orr..1
M (address)
ma
tS (section) r J, t .3(lot numbe() (grave number)
GName of Sexton or Person in Charge of Premises t, wi
2 (please print)
W Signature 1. Title OW PI 19Lud.
(over)
DOH-1555 (9/98)