Russell, Jr. Judson if 31
NEW YORK STATE DEPARTMENT OF HEALTH 4 ti
Vital Records Section Burial - Transit Permit
Name U d n Middle C l T.Q` I , r . • � ,
z
•
``;j Date of Dga� ) If Veteran of U.S.Armed es, .
>f-; r' 1 1 2S War or Dates I�
Place Bath Hospital, Institution o�rt ��,, I
City Town o Villa Street Address L. veyl-- Hea-1-lh ca,c,/i k.
a MannDeath VI Natural Cause c ident Homicide Q Suicide Undetermined Pending
tt Circumstances Investigatiote
Miiiedical Certifier i . Name • Title
m3 Death 'icate File 1 D ct Number L R ster Number
=t' City Town qY Village �q
J' Dg to ► v etery or Crematory
❑Buria l 3 /�0)a ) U),-Q-Lk, CY\c:C IscJ r` \.�-
Address •
Cremationci
ZDatePlace Removed
'. ❑Removal . I and/or Held
M and/or Address
= Hold •
0 Date Point of
Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 � Registration Number
1` Name of Funeral Home B '�� r c .,_( 4=ci0.i4kk )\4 &04 i I
. : Address
.Av
°.1- C huyi N St- L La Ze rrA.c. N f laq`f G
:"` Name of Funeral Firm Making Disposition or to Whom
IRemains are Shipped, If Other than Above •
Address Ill
kit i hereby granted to dispose of the human remains described above as indicated.
Oif Date Issue 1 (3 l&C)a Registrar of Vital Statistics q• C 3 1 ,..
{:.. (sig ture)
(•
District NumberSb c Place I (� 1 ' • ,
4
I certify that the remains of the decedent identified at3ove were disposed of in acco •. th this permit on:
F
Z Date of Disposition I/1 i i 12 Place of Disposition i tn., c-U rt�
. (address)
x (section) / (lot number (grave number)
GName of Sexton or Person in Charge of Pr ises L (i All,,r ..t N�f
Z (please print)
14 Signatuie Title CQE *z0�
(over)
DOH-1555 (9/98)