Wolf, Robert r �.
NEW YORK STATE DEPARTMENT.OF HLIALTH # 1 ( K
Vital Records Section Burial - Transit Permit
Name First � � Mid_cjle / Las „ /� ` Sex
/11
iN Date of Death j/ Age Mille/
Veteran of U.S. Armed�orc1ees,
7 - /-S-czW 3 15- War or Dates 72O..ig,,,. Place ath �. Hospital, Institution o �4 4• Ci Tow or Villag a Street Address
Manner of Death Natural Cause ❑Accident 0 Homicide El Suicide 0 Undetermined Pending
gl Circumstances Investigation
Medical Certifier Name 069Title
Address ; Ll �l[��-w� rC�o�
'' Death C-rtificate Filed /� /JJ,��/"
iiiiiii Ci Tows sr Village
, �- L_-G% District/s�'r Register Number
Date Ce •ry or Crematory 1
:::< ❑Burial -(5-- /3 f ��u, C �LJ%rye �--a�x�
n ::ess
>: I J Cremation '�j
i G�✓C /
Place Removed
0❑Removal and/or Held
-•• and/or Address
gHold
O Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
:::: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
gli Name of Funeral Home 4 X�' :r�lJ,�t 4.a. y .) o a, gS
imi Add ress
A.,_,1- 4=--....., 2ze /1t-› 7
...,,,i„.„.„.„-, Name of Funeral Firm Making Disposition o4_„ ,,,z--orn
viti Remains are Shipped, If Other than Above
A• ddress
'' Permission is he eb granted to dispose of the human remains described abo . 'ndicated.
io Date Issued /S p/;� Registrar of Vital Statistics � cf 4:.
€_i (sig f ure)
iiii.iiiii. D• istrict Number 576-4 Place He`s' C X , 7Z‘J / / /2_. 2 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
D• ate of Disposition 9-16-13 Place of Disposition 'E„ct/ (, . to t w._
2 (address)
CC (section) / lot umber) (� (grave number)
GName of Sexton or Person 'n Charge of P emises G �3 �_, �tcwt�'
g (please print)
4 t Signature `,,_, Title ( ol1i-1 a
(over)
DOH-1555 (9/98)