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Mitchell, Robert 4 ( 1L NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit Nam First Middle Last Sex Kober C M1fcie-I1 Na IL. D e f Death Age I If Veteran of U.S. Armed Forces, 1.3 3©13 ce7 , War or Dates l 9 le / — 1910 I P ac of Death � ) ! Hospital, Institution or 0 a City(fow9)r Village 1-1-ad l t Street Address 0 Manner of Death Natural Caus4 J Accident 0 Homicide 0 Suicide ID Undetermined 7 Pending Circumstances Investigation iii Medical Certifier QQ N me Title fl /ROd e Li A4 D Addres cS 0�- -a. Ct ►r i rl L y . Death Certificate Filed ' Dist t�r ; Register Number City, Town or Village 1 L S 2 1 Date ``�� 3 Cep tery orvr m ryCrt-o ' �� El Burial v3 -D � -�d/ ��,� x.a>toly___, Address ®Cremation Date Place Removed 2❑Removal ; and/or Held and/or Address N Hold 0 7 Date , Point of aQ Transportation Shipment 5 by Common Destination Carrier Disinterment Date Cemetery Address i Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home ).l £ --Ctue.A_ \jl 0 // ( "--(1) C1 Address C!l a �J( L� yIt �oZ�t( co >3 Name of Funeral Firm Making Disposition or to Whom / Remains are Shipped. If Other than Above 14 Address ir Permission is her by granted to dispose of the human re .:.Il, s described above as indicated. r Date Issued Li Ool Registrar of Vital Statistics 0-c.,--e-c 6 (s''ignature) District Number 1ti_S Place0 ' 7/46C& I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i- {� • Date of Disposition t l3 Place of DispositiIlion "t',jAcsi Csim jur+vti (address) W !s (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises f t +jL �et,►4tt- a (please print) W Signature s „At-- Title CI r4icr t DOH-1555 (10/89) p. 1 of 2 VS-61