Raynor, Kenneth /34
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ri
Name First Middle Last Sex
o v
is Date of!peat Age If Veteran of U.S.Armed Forces,
3- _ 3 S War or Dates �/�,/.
' Place of y Hospital, Institution or
-.-,-,•• City or Village A- /,!APLi/1 Street Address J,�� d"1 _
Alr
Man of Death Natural Cause Accident Homicide .�Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name ' Title
I Address AP/ 1--4
Death Filed strict Y----c,p7'ter,t;elo/o,
.-rReg�ter tuber
City own V ll ✓ GG(L✓ c c� ✓- I
❑Burial Date Cemetery or Crfarpatory
��� 0-3 -/y-/3 /`�j-u/ Vie-L../ (✓P,rfr) w A
:;.Cremation Addre(.&A 1, ke / PcZ O w ee,,,.-s //J/ /g c%
Date Place Rei need
- 0 Removal and/or Held
1 Hoid
and/or Address
1-€ Date Point of
�'Q Transportation Shipme
nt
by Common Destination
Carrier
`}- Date Cemetery Address
gia Q Disinterment
M1= Q Reinterment Date Cemetery Address
r Permit Issued to Registration Number
Name of Funeral Home 1-10„/nat d bb„..maker Funer cal rrn 01 `y a`
Address 11 La-Cal c ile- SA. , Qu eensbur y , N e vJ yor L. 12 o y
_'- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
al
Permission is hereby granted to dispose of the human deec ribed as indicated.
al Date Issued 3-//./-d-{)/ 3 Registrar of Vital Statics � -
l ' /�J
District Number 7S3 Place /2f2
gi I certify that the remains of the decedent identified above were dispos in accordance with this permit on:
2 Date of Disposition 3-/c=13 Place of Disposition PAM.-��/1 i 0,004,4/(1 5/
_ (secion) ,- /2(tot ) (grave number)
Name of Sexton1Pon-j, geof Premises ����W �' "i,o'/"0 `--
r /�� lilease t
Signature ti "l`'" Title ae(-1'1r4°2 }l•S 4-,
W.
(over)
DOH-1555 (02/2004)