Richards, William NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
iiiiiiiii. Name First Middle Last Sex
Date of Death Age If Veteran of U.S.Armed Forces,
1ZI1e' F'°\ ?-1 War or Dates Iq93-iR4K0
f4 P =ce of Death ospifal nstitution or
own or Village ►ens Ea\\S , NJ'( Street Address C11-e.n3 '\\S cS t l
ke
Manner of Death Natural Cause Accident Homicide Q Suicide Undetermined []Pending
la Circumstances Investigation
tit Medical Certifier Name Title D 0 J en n, er ran
Address
1Op fo.r(, Gteyes v--4t\\S, !v./ 12 O'1
:::' Death Certificate Filed District Numbe ` Reg Au r
`=` City, Town or Village ( t e.Y�s ca\\S Nssi 1
> ❑Burial Date Cemetery or remato
1 Z I 1I )2.D13 .P;neV;cto Crevra :
❑Entombment
Address
.:Ei®Cremation L,`Q� 12.1609
Date / Place Removed
❑
Removal and/or Held
itand/ Address
Ce Holdor
Date Point of
tti
Q Transportation Shipment
ci by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
111 Name of Funeral Home Gy flaxk� r Q` ( 0 4 13 0 __
Address Nevi /orL 12sdOL\
-- -- 11 a-F�yQ�e- S-�. Q�.-leensla.�.ry .
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
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ru
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 Z/ie ` )3 Registrar of Vital Statistics (JVCA_, ..e tz ),t &
(signature)
is District Number 5 6 0 1 Place 6 CMS rck i 1 s, Ai c J
''" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k ,�
la Date of Disposition ta-la-13 Place of Disposition , n1`1 ( c r`
(address)
UI
Art
ir (section) (lot num (grave number)
Name of Sexton or Perso in Charge Premises "Ail, ,.... -
r (please print)
1 Signature Title aietimett
(over)
DOH-1555 (02/2004)