Upton, Albert NEW YORK STATE DEPARTMENT OF 1-4EAL;rMd # 4")
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex M
R I ham v- l'Cobe,A-- a OorN
Date of Death `` Age If Veteran of U.S. Armed Forces,
.n hi- l to 3 War or Dates
}- Place of Death Hospital, Institution or
City,(row or Village ��r Cd,.,Jcc-pl Street Address ,,k t -.ol Sct" NJ r 5 i'- \-614
0 Manner of Death viriff Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
0.
Circumstances Investigation
in Medical Certifier Name Title
Address
Death. - - ate Filed District Number Register N mber
Ci , Town Village cJ�jc ,f'7
❑Burial Date Cemetery or Crematory
� ' �\ 3 e%n c J c,....i C I'c.w.� 0
❑Entombment
Address
RCremation 2-1 QJ 4 kV\ c Lee nsbJ 1 I Lgoff
Date Pace Removed
'Q❑Removal and/or Held
and/or
H Address
Hold
CO
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
i:i ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Ni Name of Funeral Home M (j )L,,1 M t �,,i-er-& 1 14ornt 0 1 0 - -9
i> Address
`323roc_01w` cvri- ol IzE28`
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
', Address
1X
t>
fl' Permission is he eb granted to dispose of the human remai escribed a ve as indicated.
Mi Date Issued "0"/ Registrar of Vital atistics` ,4_4(_,../.1 .4,,,a.
iim
(signature)
iiiii District Nu ber ,_i-, — Place f
I certify that the remains of the decedent identified above were disposed of in cordance with this permit on:
Ill Date of Disposition 5 )//3 Place of Disposition R � (,),,,,r„.4.,),/
(address)
ta
to
c ` (section) (lot number)) (grave number)
ta Name of Sexton 'P i e of Premises / �) G'
2 _ j (please print)111 / j
Signature / �j Title ,fiy►?I� d / ‘
(over)
DOH-1555 (02/2004) •