Benware, Robert NEW YORK STATE DEPARTMENT OF HEALj71 1
Vital Records Section Burial - Transit Permit
Name First L Middle Last Sex
iA
ttj9e('�[. , C Z w•a(tC-
Date of Death Age --_7 f Veteran of U.S. Armed Forces, 1 7/ 3 fo/y- / 7 War or Dates
.j., Place o o-= Hospital. Institution or ��
Z City, ' Village Cy 11`,,I.- A. Street Address e�
2 Man : Death Natural Cause ED Accident 0 Homicide El Suicide Undetermined �Pending
Circumstances Investigation
W Medical Certifier Name Title
CIMi6.4,k. Q. &11 MD
Address
t Piii,er Ave,, .t. ALr. )a x )-
Death •Prt icate Filed District Number Register Number
Cit : Town Village a F. u 41-S-s- •
Date Cemetery or Cremator
Burial 7// 7!/ ?4/r :`1 e_tt.'r.-...)rc4-4-4.0
Address A1 c
NI Cremation awe e4 , r ) 6v c r
Date Place Removed
Z Removal and/or Held
and/or Address
- Hold
0 Date Point of
NU Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �- Registration Number
Name of Funeral Horn 4,r arm ,,,,,eft,( !4' ''t` , f30 �`/"g
Address 7 t A,o,,, Ave ,, 1.. .-- Ai v 1 a 0..2_
Name of Funeral Firm Making Disposition or to Whom '
t Remains are Shipped, If Other than Above
Address
u
4
Permission is he eby ranted to dispose of the human r a ns scribed ov s ' icated.
Date Issued 7 O 6 2o'7' Registrar of Vital Statistics i(/I/t.
a re)
District Number 4rs5'3 Place [-= I- 4-At— ( - /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i— p ,r
W Date of Disposition 1/1Iiv Place of Disposition EviA^.A., ew4tOtI..
(address) _
W
0
II (section) Zinumber) � (grave number)
pName of Sexton or Person . Charge of Premisesit
(please print)
W Signature4 Title Ci2C1^174-.
DOH-1555 (10/89) p. 1 of 2 VS-61