Bruno, Richard I tr33
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name 1 G4 Fir t Middle Last Sex
K A 4 ,+
F'• ► N-(-)Al 0 /-
Date of Death Age If Veteran of U.S. Armed Forces,
0/ �. - �/
A017 War or Dates /9 a — /
14 Place eath Hospital, Institution or
City Tow Village Ticcw4eruvq, Street Address mos0.s Av1;p_97dv /l)vrsi`e% h jn94-
Manner of Death Natural Cause ElAccident ❑Homicide IDSuicide ❑Undetermined i Pending
1,14 Circumstances Investigation
j Medical Certifier Name s� Title
0 6/4'P C4nQ MAi) 0
Address
/off j?P c,4— TT n :.k -ect I frrit►Jci4+-E5 Q- My. /07 4 3
Death Certificate Filed _ _ District Number Register Number
City, Town or Village /i.ccmiere,S a. �/ o Y 62
gi❑Burial Date etery or Crem tory
❑Entombment �� �� �n`0/ i k t v)Pam; e j^e s-i p%o r
Address
®Cremation W e.eNy 1 u ry It, y
Date Place Removed
❑Removal and/or Held
and/or Address
fa
Hold
0 Date Point of
0 Li Transportation Shipment
O by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiiiR Name of Funeral Home Ei:A rid_ b -4 routp I 0--- ate 3 I?
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
l
f!'i: Permission is herebi granted to dispose of the human re sins described above as indicated.
ig Date Issued Fjll i a0 J V.—Registrar of Vital Statistics .ex—,(..-J / ) .
/ (signature)
ill District Number �i'(� `'� Place e Olu Q rQ,5 &J .7 , / 8_3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition I/it Al.. Place of Disposition -R.1 Ulu.) (re^mc-foriv"-'
a (address)
til
w
CC (section) 4 (lot numberk- (grave number)
Name of Sexton or Per on in Charge f Premises r,s-} li - 3eanalb
2I(please print)
la Si nature Title CQL:mRik
9
(over)
DOH-1555 (02/2004)