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Forth, Robert NEW YORK STATE DEPARTMENT OF HEALTH --711 Vital Records Section Burial - Transit Permit Name First Middle Last Sex lc)\O e r - rc C;S -For- FA` Date of Death Age I If Veteran of U.S.Armed Forces, zIon f 2-0%3 Lq1 War or Dates 1gL©Z9 -\c a`t} Place of Death Hospital, Institution or ,Town or Village Gi teANs F'\\s Street Address G Lens "ak,\\S \\os.Q, -1--c ( :-..z anner of Death�1 Natural Cause Accident Homicide Suicide Undetermined Pending 4� �! Circumstances Investigation Medical Certifier Name Title x C- iaca\ \(1'(\a\ ., c C-'\ Address too Par-`(- S --reed C)—'s ca\\s , ,N)-.1 1-2-bcA . Death Certificate Filed District Number R ister 1r `�Cityr>Town or Village C�Qr'S Fa\\S Date Cemetery or remato ::: Burial 1 z-1 0G �\ p,r'a \I ev- Ct".erna r.// Address r :::: (Cremation Lv�Z1Sb�r.p) Jam') 2 Date J Place Removed ❑Removal and/or Held M and/or Address a Hold 0 Date J oint of to Q Transportation I Shipment a by Common Destination Carrier Q Disinterment Date Cemetery Address Renterment Date Cemetery Address ' Permit Issued to Registration Number ;' ,r Name of Funeral Home Hc cud �) Fw, 'esker ,era/ Horne_ 01130 h Address 11 Laraa.y eat. , bu:eensbu , New sorb 1a?�oy 1 Name of Funeral Firm Making Disposition or to Whom x, Remains are Shipped, If Other than Above Address , (.4, Permission is herebygran 'bed abo as ted to dispose of the human r ins des indi ed. Date Issued I`ZD9 013 Registrar of Vital Statistics QZ �v� ,d' / . ' �-a; District Number 66,0 ( Place /`C<J- v J I certify that the remains of the decedent identified above were disposed of in accordance with this phrmit on: ta Date of Disposition id-11-13 Place of Disposition -at I/ j 63h-A 7r,- w (address) IA CE (section) A (lot number) (grave number) DName of Sexton or Person in Charge of Premises i s It- S vivcd� Z4(..._ (please print) .. Signature Title (Taw/o/r4 V II (over) DOH-1555 (9/98)