McDonald, Ronald NEW YORK STATE DEPARTMENT OF HEALTH f. 'I 6 7
Vital Records Section `r- i Burial - Transit Permit
Name First Middle Last Sex
iiiiiiii R/JA/d_ • DA Ls ith (nt,a fkl A 14_
<<€ Date of'Death Age If Veteran of U.S. Armed Forces,
0 8— Q F- ?8 War or Dates m
Place of Death Hospital, institution or ' ff
2 City, Town or Village j1 �.h ti A Street Address yj F Oh41 LOOOJ.,s stud iL
QManner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Na e Title
O e. Frip L)p A /
Address
c7o '7J L pVie- PA)�a. ray , /g, -
Death Certificate Filed District Nup 4 Register Number
Villageiiiiii PI City, Town or ;Ni,r'u'A t:.
Date Cemetery or Crematory
El Burial 68 - /A- - ?BL V/Ne- Vie-u eaQisN, A
Address
�remation 6 t) 0, 01-‘y
Date ` Place Remove
g❑Removal and/or Held
rz and/or Address
g Hold
Q Date Point of
DI El Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiii Permit Issued to I Registration Number
i Name of Funeral Home M. a. 6-'j/r)er Fiiiej / 0010e- 0/ q
Address s-a- J3roAd,tt'P'r Pofl 14- oA f N-T, ! e- &g.. .."
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ii Address
Permission is hereby granted to dispose of the human r ains described bove as indicated.
Date Issued O8-Or-- A)a Registrar of Vital Statistics , ��
.01 (signature)
s>< District Number /s.51: 9 Place Mi,iq.vA 19,/
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tip
W Date of Disposition ' /tL(I 15 Place of Disposition -FRO 40 (�'ins{priv,
2 (address)
4I
(/) •
cc (section) AI(lot umber) (grave number)
QName of Sexton or Perin Charge of P ises A J IA '
g (please print)
fJ! Signature 7 Title CIZ61/ 1-trCE,
(over)
DOH-1555 (9/98)