Buttles, Richard 1r5S(o
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section -* • 0. Burial - Transit Permit
Name First n `Gafi� / Middle g Lads_ Sex
L -w Le?
Date of Death Age If Veteran of U.S. Armed Forces,
/0/ 1 '/ .olZ g..5— War or Dates
1 _ .f Death Hospital, Institution or
imp
or Village Le 5-�-a Us Street Address Lei - 0-- fit
- ner of Deathiwi Natural Cause Accident Homicide Suicide ❑UndeterminedPending
tti Circumstances Investigation
at Medical Certifier Nam Title
M
1 Ho,,,Etr.\ SZVC r / ~
Address
3 i � ,RcuA.3„„„ . &cL ( J, tl. % ��bAt
Certificate Filed ! District Number _ ) Register Number
City, own or Village (9Len S-- "'-�I lc- S 6°.S- Ltif 3
<;:Burial Date Cemetery or Crematory
likev:e,...) ac ,..,1.--1:a/
is❑Entombment Address//. A , �,,//
:>miCremation . E v...c_e_.1.s �F /vc T rl/l
Date I . Place Removed
❑Removal and/or Held
' and/or Address
i= Hold
0 Date Point bf
Transportation Shipment
L by Common Destination
Carrier
ID Disinterment Date Cemetery Address
iiiiEEl Reinterment Date Cemetery Address
iliii<> Permit Issued to �-- Registration Number
�—
Name of Funeral Home ?)--e,-----4.,,,,,!t �4c re-( H"�^�) 4 '- - P 119
/`/t
'''` Address
Name of Funeral Firm Making Disposition of to Whom
Remains are Shipped, If Other than Above
Address
i
IL
Permission is hereby ranted to dispose of the human remains %esccrribe aboJ� indicated.
Date Issued d /Z--- Registrar of Vital Statistics � �•1 GZi��`�
�� `/ 9
(signature)
District Number 4/ 8 Place � � /J'-"'> %0r1
Ililit 3 �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition i o- i ri L Place of Disposition ZUttJ 1,"d �r L
2 (address)
U
VI
CC (section) /, (lot number (grave number)
ci Name of Sexton or erson in Ch ge of Premises
(please print
III
iiiis Signature Title REM111-t
(over)
DOH-1555 (02/2004) '