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Ross, Stanley
E 1. It NEW YORK STATE DEPARTMENT OF HEALTH � .3 Vital Records Section Burial - Transit Permit Name First E Middle Last Sex], /^ Date of De t Age If Veteran of U.S. Armed Forces, a 0cpla : WarorDates -l9'„4P(e - 19(07 ce of De h ; Hospital, Institution o Town or VillageZ ' Street Address . Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined P nding Circumstances Investigation til Medical Certifier Name, Title fl toxc.� C>aIn1ii -an.) to J4D Addr i s Pctrls s- V tub caj� ath Certificate Filed 1, /t5 Its ! Distri ue i Register Nye bar , Town or Village �,l /y� Date C tery or Cr matory /1 ❑Burial 1�Address -L � 11 c,Cremation 1.1�?�iyl,0 b� 2 Date PlacJ Removed ©❑Removal and/or Held and/or Address Hold fn 0 Date Point of tl)Q Transportation Shipment 0 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date , Cemetery Address Permit Issued to �- � (O Regist�� Number umber , Name of Funeral Home �)' x ' C _ Address0_4 0.4Il,l.l'cil Lst !--a La viii ion g ko Name of Funeral Firm Making Disposition or to Whom r,its_ / Remains are Shipped. If Other than Above tAddress Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued L/ / 3 U/3 Registrar of Vital Statistics J W (signature) District Number V Place 0lP-/2.5ra/f /C1 y f I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ yZ Date of p DispositionRoilltt-i1r GfUr1v . Dis o'sition �'�0��3 Place of W (address) tA CC (section) Aof number) ( rave number) dName of Sexton or Person n Charge of P emises :1 /ha Z (please print) UJ Signature Title Cf1.041OL DOH-1555 (10/89) p. 1 of 2 VS-61