Barlow, Richard NEW YORK STATE DEPARTMENT OF HEALTH - a" •
'Vital Re Section Bursa! - Transit Per
Name First Middle Last Sex.
Ks,C-._Nnara Bal--lou..) M
Date of Death Age If Veteran of U.S.Armed Forces, .
03 /ZLQ�aoi`f (0 Z- War or Dates UnY,fO1),))e)
Place . •:-. I Hospital, Insblurion or
CitY awn , r` '-, 40 Ad Street Address 5 J g z Cg1\o cc i (Z,00 cl
,;, Manner of ° << 0 Natural Cause ❑Accident [Homicide ❑Suicide ❑Undetermined 0
PCircasustances ending
'- Medical Certifier Name Title
M .1CNa2i S; v,:v-‘;Cc&
Address Y 57 Grarli Aqe„ a)k ?0�a SQ�:r s Al 1o�
. u Death Certificate Filed D t Number " Iegister..Number
city,Town or Nnr-l-119 ►�r r/o►.Id '-et L)
Q Datey
Address /
=- Date Place Removed
;0 Removal and/or Held
and/or Address _—
Hold
Date of
`f El Transportation rant
3 by Common Destination
Carrier
-_ [i Disintenriente Cemetery Address
0 Reinterment Date Cemetery Rddruss
Permit Issued to Registration Number
Name of Funeral Home Ncur j rd b. er Funerai /1om� Oh)3
Address /I LaFay.s✓#e (5 - ,6u2er)s 1 A] ' rk- / 2(YJ
i s Name of Funeral Firm Making Disposition or to.Whom
Remains are Shipped,If Other than Above
Address
4 Permission is hereby ranted to dispose of the human remains described above as indicated.
r Date Issued L g 7 Registrar of Vital Statistics b17
(signature)
District Number L t 5Q Place 147./I72 (V itin 1-4 willapr IOJV/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3 ./'/ Place of Disposition ?,v,t(7!�-z/ afic--/eiy.%9
r-= (a ress)
m
(section) < �'/ , 7ber) ^' (grave number)
Name of Sexton Charge of Premises /`1✓IG'
f (please print) �� Jae"
Signature Title l2� 7 .
f
(over)
DOH-1555 (9/98)