Uhe, Robert N 4 Uo 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name rst Middle Last Sex
Date,of L A Death/ e If Veteran of U.S. Armed Forces,
L `Z I c�=-0 a War or Dates
t Place Bath Hospital, Institution or
W Cit Town Village � .,veep►s b r Street Address 1 a 014 ��w� goa A
W Manner o eath❑Natural Cause C ident ❑Homicide 0 Suicide El Undetermined �Q'Pending
Circumstances }('Investigation
W Medical Certifier Name Title
o t L) r � tc_m- c . Gr1v Cyr►
Eid Address ICA_ ecr.d__ _erfou.in i r) -i ia?1---"?
5 Dea cate Filed Dist;v Number R gi r Number
Cit To no Village ��d2 - (..D .-7
D to ii 1 Ce Try or Crematory
❑Burial t g t 0-0'l�
❑Entombmentd �l�ul`Q�`J f
Address
'Cremation c 11Le-e
Date Plate Removed
Z❑Removal and/or Held
O and/or Address
7 Hold
rn
Date Point of
a❑Transportation Shipment
• by Common Destination
Carrier
P Date Cemetery Address
❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Hom�-7AAo e__ -.F.AAer,.1_ -�r.� - 0a1/41 Q
Address
Name of Funeral Firm Making Disposition or to Whom >/
1 Remains are Shipped, If Other than Above
• Address
ir
zPermission is hereby granted to dispose of the human re a' s described aboveps indicated.
Date Issued! ( I j 13-01, Registrar of Vital Statistics �_ ` '-.____,
23 _
(signature)
District Numbe gc Place )Q L( (5 U....c _y.
HI certify that the remains of the decedent identified above wer disposed of in accorda with this permit on:
W Date of Disposition/1 l02-j� Place of Disposition it-VVA_ V/ice✓ CeitoemitA--/
2 (address)
W
CO
(section)�� �f(io/t,�ber (grave number)
pName of Sexton or P n ' Charge of Premises L/[�/�.✓
Z (please print)
Signature �n� Title dA t-
(over)
DOH-1555 (02/2004)