Wright, Russell f -
NEW YORK STATE DEPARTMENT OF HEALTH ti 14 Z
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
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hv.SS e.\\ kev-u, U�c-;q� �1
Date of Death \ Age If Veteran of U.S.Armed Forces, •J
\ g War or Dates I14Cc- trig-7
r Place th Hospital, Institution or
C� Town Village F0,1 Is E.SUJ C\r Ck Street Address 1-0 sr
;; Manner of Death �v.�St3✓1 �c,�rs;.. �-ton-t
Natural Cause ❑Accident Homicide ❑Suicide �Undetermined Pendin�
Circumstances Investigation
. Medical Certifier Name Title
-,. NarlicLi S d c� ek m b
Address
FO rd- kv)-{i.504. 1J urC;v.c 'k-CD
.e.1 Death ; u cate Filed
C.
District Number- T R��er Number
C , • Village For\- E &iu rdt .1 755—
Date Cemetery or Crematory
❑Burial 1 Z j C�q .? r)1 3 -tom; :cA.0 G y
Address
:•:•:RCremation Q v.12Q x15\1�r� i /01 1 Z
Date Place Removed
1-1 Removal and/or Held
and/or Address
a Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address ii
. Permit Issued to Registration Number
N Name of Funeral Home Hi� rd V. ker Funeral home. 01130
-'; Address I/ Laf ,J
aUyl to of. , C4u e..e�sbu t 1Je o 1 04e- /g gol
z Name of Funeral Firm Making Disposition or to Whom
c Remains are Shipped, If Other than Above
': Address
.
•C' Permission is. h granted to dispose of the human r ains descri ve as indicated.
.�t; Date Issue � /3 Registrar of Vital Statistics �z, 4_
. ------- signatu _ /
District Numbe�7� Place
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F h /�
$ Date of Disposition R-10- 3 Place of Disposition n41i++d 'l.r pf3-
(address)
ISS
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CC (section) IA (let umber) (grave number)
AName of Sexton or Perso in Chargsl of Premises
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(please int
� print)
44.1 Signature ( Title G 4#imL
(over)
DOH-1555 (9/98) •