Davis, Richard 4
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First a Middle Last Sex M
ics,c..h c x C _ _ (�0.\1 c
Date of Death Age , If Veteran of U.S. Armed Forces, ye S _C'Q4e s ��
3 ►5�ao►3 (� War or Dates
F- Place Bath
WCit Town Q Q-)a t r(1 i `'treet Addres 5 2- hods- Nan GI A/e . -- —
p Manner oT eatfxh7l Natural Cause Accident Homicide Suicide Undetermined Pending
W (X� Circumstances Investigation
Wr Medical Certifier Name Title
c aaV Merry hem;
-- ------- - � -I
Address 3tq RA a1 .n- 1--t..m..i J1-N I a�0y
Dean •-rtificate Filed District Number Register Number
Qt� .,nS _ fc-ow :: d 2-.-
❑Burial I Date 31
s gii 3Cremator •
❑Entombment — — �—
Pv
Address //,�,,
Cremation 1_V WA-k al (15 '� -- Ij-S.®`-1-
Date Place Removed
Z Removal and/or Held
Q and/or — ------ ------ ___. ------_— ------ - -
Address
— Hold
0 Date Point of
NQ Transportation _ j Shipment ___________.—__
C by Common Destination
Carrier __ _
Disinterment Date Cemetery Address —
Reinterment Date Cemetery Address
1 i
Permit Issued to 1 Registration Number
Name of Funeral Home Gy fl b, 60,ker Vu..ner 6_i iio(-rt.- 11 f 3 0
Address
I1 talayc_ 41( JA. , &ULCenSbu(y , tiC S 'JO1- Ir_ 12 U'-j
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above _— _i =
2Address
a' Permission is hereby granted to dispose of the human rem ins described above s indicated. —
Date Issued 3-/S- goo Registrar of Vital Statistics
(signature)
District Number tes-? Place
JO...--f. c.-t,- --0_1„....------ _
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tti Date of Disposition 3-6 (3 Place of Disposition _ 4/�j J 04 4 thee.' —
2 (address)
ILt I
CC
(section) umber) (grave number)
Q Name of Sexto r Per a arge of Premises --.---__=� o
Z f (please print)
Signature Title Ci.evq-4L--
(over)
DOH-1555 (02/2004)