Purdy, Robert 6 8/
NEW YORK STATE DEPARTMENT OF HEALTH is. . - tr
Vital Records Section Burial - Transit Permit
Name Fir At Middl Last Sex
p o .0, j J'l 1,-4 Pi
Date f Drag ) Age ) If Veteran of U.S. Armed Fords,
��` �/ �` War or Dates / 9s`4- — r f j 0
4 Place of Death Hospital, Institution or
City, Town or Village l'f, Llar1 t^ii, Street Address /IS" it;N7r Tr{-4--
W !�
Manner of Death j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
- Circumstances Investigation
43
tu Medical Certifier Name Title
t b O �Lii-0 /)Z 'J
Ad ess
� Aru S7-- )ii. ,q-1)iz-ATvw7 a-93 --2--
Death Certificate Filed District Number Register Number
City, Town or Village a{:i<a 6 1hJ j ) �S�p� 5/
❑Burial 1 Date Cerng tery or Crematory �--
❑Entombment /1— /ti" ' i 3 I r` W c.._- {I��iL' c--i'`f 0l t�t c /
Address
b[ remation 61, iLt�� /L1gj ` /)oL
>.:: Date Place Removed
❑Removal and/or Held
and/or
Address
WI
Hold
0 Date Point of
5 0Transportation Shipment
ES by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Mi Permit Issued to Registr-tio Number
Name of Funeral Home ;Ak-4, k - /ti �-4 Piers j 6i._— ff,;, cv-sif
Address �!
• Se--.4 .,..t 4 P , l 4.1-tew
Name of Funeral Firm Making Disposition or to Whom
• R• emains are Shipped, If Other than Above
a Address
i
'°" P• ermission is hereby granted to dispose of the humah ains described above as indicated.
niiii Date Issued t1-Nd _ < i . Registrar of Vital Statistics - G�4�J3Y�--
_ (signature)
District Number/ 5 Place Et/
ini
G�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Date of Disposition f -140,3 Place of Disposition ,�j.,V f� V.�W (iekerAh.4—,/
a / (address)
ILI
co
cc r (section) Zttymbet:f (grave number)
.�Name of Sexton o Per arge of Premises
2 /', (please print
S• ignature N U4 Title f..W...or4 f?;t f-
(over)
DOH-1555 (02/2004)