Randall, Harold NEW YORK STATE DEPARTMENT OF HEALTH 4 7 Z
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Vital Records Section Burial - Transit Permit
j. Name First ,, // Middle Last Sex '
t i e 4i / ?Ei2 ?/24tie gL-6- I1,9z --
j Date of De4iAge If Veteran of-U.S.Armed Forces,
` D/ O s War or Dates � J
«a "Place of Death Hospital, Institution or� " .� trtution ..�
City,Town or Village 0.4. -E JJ t--61.z-S Street Address Et- ) 9 Z 4$ Pr7 -
Manner of Death El Natural Cause 0 Accident 0Homicide 0Suicide 0 Undetermined , 0 Pending
Circumstances Investigation
Medical Certifier Name '�, -Title
S U:. "9.Afid dT/¢Y e s.r > k-1.-
Address
lD d /.se s?- 6,( D rr9-u s Air ,60e
c:;: Death Certificate Filed r District Number Number
City,Town or V!._.. e S ! x-4S 5 6 0 /
DEnt
:..!EIBUrial I Date/c7W272d/3 Ceinetilry or Crematory
w giCCre ma A oC/ 4 .����I-LE/ .ASS 3 4.,2 y dV I
Date Place Removed
rlz 0 Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
• Carrier
®Disinterment Date Cemetery Address
..: [�Renterment Date Cemetery Address I
Permit Issued to '/ ' Registration Number _t
' Name of Funeral Home ,os.tS�-- 1` ". JAv'C._ , /44723—
rr Address 9-1-e..-S A)7 /8. a
▪ Name of Funeral Firm Making Disposition or to Whom
T Remains are Shipped, }peed, If Other than Above
Address
tr
Permission is hereby granted to dispose of the human mains 'bed above as indi
Date Issued /a/o' v/. _ Registrar of Vital Statistics �Q-4 ,-/-) , 9'-e
((eignatr3re)
District Number �O/ Place G =- //
L72 V
I certify that the remains of the decedent identified above we disposed of in accordance with permit on:
Date of Disposition it-Z13 _ Place of Disposition • '&e Lj et itl _
(address)
1:7-� of (section) nymber) (grave number)
' 4,)(lot
Name of Sexton or Person in Charge remises t«•-€tt
(1,14se Print)
/4Signature Title 1Nt>v0
(over)
•
DOH-1555(02/2004)