Caswell, Robert NEW YORK STATE DEPARTMENT OF HEALTH r ' 10
Vital Records S:,.ection ,.:..� . Burial
A..�- Transit Permit
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Last
Name First L�-` eigS 4.3 e___L C. Mi__
`Date of Death �a�/� �� If Veteran War or DatesS.Armed Forces,� /✓
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Place of Death ,/ Hospital, institution or
City,Town or Village 69&(YS /iui$ Street Address #7 )I& tsbv 4il2
r Manner of Death[ �Cause 0 Accident 0 Homicide Suicide termined El Pending
MI
rii �l Circumstances Investigation
71 Medical Certifier Name � 6�bp Title A
Address ,�
/6/ .� y , &LLCE A•401/14r iuy / y
Death Certificate Filed District Number Reg ter umber
C ,Town or Village Sid c
❑Burnet I ate Cemetery or A
/b /07d/3 , tj/ � -/k) a-es -�'t RI il/`(
❑Entombment Address:l Cremation 9/ £LUA 4044 AdO'erY Ai
-/ � ,
Date I Place Removed
e
--❑Removal i and/or Held _ __ _
/or Address
Hold
,. . Date Point of
�]Transportation Shipment
ip by Common Destination
Carrier •
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit issued to � / I Registration Number
'A� Name of Funeral Home ) �~ J. ^/I_ I f ilr S
iii> Address 43/ 45/%("&d SG/J.([j (5 A /c3, (J u
r: Name of Funeral Finn Making Disposition or to Whom /Remains are Shipped, If Other than Above _
Address
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,,,, Permission is hereby granted to dispose of the human remains d: - -. - • a
Date Issued /0/07/20i3_ Registrar of Vital Statistics l s
(signature)
• l C�<
District Number .360/ Place 4 O� ��h �T+
,„,„„,
"` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition fO( /I3 Place of Disposition — • Po4004 01'1.IV _
(address)
M
,4 (sedion) n ) (grave number)
Name of Sexton or Person in Charge of Premises r•i a
l ( ice)
Signature Title LYlEt11tt d1�
(over)
DOH-1555 (02/2004)