Ray, Richard NEW YORK STATE DEPARTMENT OF HEALTH r # S73
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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Date of Death Age -Jf Veteran of U.S. Arm d Forces,
_ 09 y�J Ol2 '7 War or Dates ,14
14. Place of Death Hospital, Institution or , /
City own ol.Vill ge Q,�-/ �.ro, Street Address � ,1 ' �.-f
��� O </� .SUS r/il.Sn // t?.�
0 Manner of Death Natural Cause Accident 0 Homicid - St.l cide Undetermined(In Pending
to Circumstances Investigation
Ili Medical Certifier Name j,-- ait„..„.0
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Addre
Death Certificate Filed .� District Numb Register Number
City, Town or Village t t„,,,ct/_ •.4'7_7)'- j 4/
;;<; (]Burial Date Ce It tery or cremato
❑Entombment Address
myeremation
Date Place Removed
1 ❑Removal and/or Held
and/or Address�
till
Hold
0 Date Point of
t �
li Transportation Shipment
is by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to %/, Registration Number
Name of Funeral Home ,a,-_ ,.iG��,s.� S`- AL& 0/1,36
Address
Name of Funeral m aking Disposition or t,. Whom
i4 Remains are Shipped, If Other than Above
Address
1
Ili
t Permission is hereby granted to dispose of the human rem ' s describe a veas indicated.
O
>: Date Issued 9-0/4 -0)0a Registrar of Vital Sktistics
(signature)
District Number„5m� Placev4'„`� ee-1
"" I certify that the remains of the decedent identified a ve were disposed of in accordance with (his permit on:
tal
Date of Disposition '�{Z���� Place of Disposition � .+
� ream...
(address)
L
t
l (section) (lot number) (grave number)
Name of Sexton or Persoin Charge of remises it
s � �+N*�
Z (pl ase print)
41 Signature �t-- CeEMierrt
Title
(over)
DOH-1555 (02/2004)