Brooks Sr, Ronald NEW YORK STATE DEPARTMENT OF HEALTH se ik it - '7_
Vital Records Section Burial - ransit Permit
Nary, First Middle Last Sex
' Kona Ict C -Brno KS �g . pta le_
Date of Death Age If Veteran of U.S. Armed Forces,
to ,D I -at) )4 70 War or Dates V( €f ( M
1: Place of Death Hospital, Institution 1 J ��., �' -
Z City, Town or Village C�len5 ra f is Street Address G l� a Il5 t� J 1
• Manner of Death E Natural Cause ❑Accident n Homicide ElSuicide ❑ Undetermined Pending
W Circumstances Investigation
ill Medical Certifi Name Title
u t F 'fir li►"\a,A MD
Ad dres
Wo�.rref1s Lk.rek N y
Death Certificate File J _ District Number Regumber
Town or Village(-, ! i r N
efr5 i Gl _5 5 I I
❑Burial Date metery�r Crem ory
['Entombment -a 3 -cc)i tine " ' /r 1 ��
Address,-,
(,E]Cremation tke ylJ( u N\
Date Place Removed
Z Removal and/or Held
C.❑and/or
� Address
tit
Hold
C? Date Point of
❑Transportation Shipment
d by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeB ,L— �,Ly ---'(Y)e- 111C-- On I I
Address lALIr01 UI LG . L_USA MIAi(0
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,' Address
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LEE
Permission is here y granted to dispose of the human remains desc "bed bo as ' ' ated.
Date Issued , L3 ZQ'' Registrar of Vital Statistics ��
`- (-,1,,,,,5
(signature)
District Number 3 I Place ectvap
I certify that the remains of the decedent identified above wer isposed of in accor ce with this permit on:
III p 1�r)('/r Dispositionwe. ifa.A., &iv)�' /Date of Dis osition Place of
W (address)
til
tr (section) Romi
er)1 ci (grave number)
Ct
Name of Sexton or P so " arge of Premises .
Z g (please print) J
tf Signature r' ! Title ( 7
(over)
DOH-1555 (02/2004)