Robinson, Cheryl NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cl'\Q / I b litsc�c.) r--
Date of Dea)h I If Veteran of U.S. Armed Forces,
! Age
I3 War or Dates
i4 Place of Death Hospital, Institution or R u�
City, Town or dl p� �C l kit I�2- Street Address �c (D(CILU 1% 1 t C�
Manner of Death Undetermined PendingIii
Circumstances Investigation
Medical Certifier Name i Tittic 0
Uecvt1 V 1 y— , f ` k�
Address
(7 iikO soo Sf ' ) C 'aluv)iI(e NV IDS' 2
Death Certificate -ed District Nu �r Register Number
City, Town or i ag: • vtl lhtAl I m€ b 2-5 I Q
Burial Da e / Ce etery or C e atory r ,,,y� / p-
Entombment 14-9-Lt ^ t r 'Etor Olin i'ai ticieL1 6aLle( !
Addres oo /
❑Cremation ( C nt 0 c l Q; v;s; oi\ST at-L e_-.\s h: c 1 I'V H l a e v`i
Date Place Removed
Removal and/or Held
9 �and/or
I. Address
to Hold
fl Date Point of
AI Ei Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address .
•
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mc �k'r FR- 61 13 0
<' Address
Lcri—:s: Name of Funeral Firm Ming Disposition or to Whom
1 . Remains are Shipped, If Other than Above
a Address
CC •
ill
0"' Permission is here y granted to dispose of the human remains de indicated.
Date Issued as 3 Registrar of Vital Statistics _
1(signature)
District Number 5_ `� Place V ` l(ttcN„ 1 utikc -
0'
I certify ��d that the remains of the decedent identified above were osedcf n accordance with this permit on:
��
Z
LU Date of Disposition `(-,2(�,_-)°/Place of Disposition I�, %' S'o.-- 9-, a-4.4.Z..., S IDkA r AA/
(address)
Ul
co 0 A
cc (section) (lot number) (grave number)
Name of Sexto r n in Charge of Premises R — _ y V.,„C.
f (please pr t)
mii Signature Title /7,�-3-'a.� )= t-/4 i5air ai al. CAf�4'
t_.-- (over)
DOH-1555 (02/2004)