Runnalls, Ralph NEW YORK STATE DEPARTMENT OF HEALTH : `4 `V
Vital Records Section Burial - TransitPermit
111111111 Name First Middle Last Sex
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; Date of Death Age If Veteran of U.S. Armed Forces,
111111111 qu6, O ? :10/.1 6 yRs War or Dates A/ O.
Place of Death Hospital, Institution or
City, ow9 or Village Q E, /S.GUR y Street Address // 7.1 e gy AD.
Manner of Death❑Natural Cause ❑Accident ®Homicide ❑Suicide r iUndetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
rr// c 1,/ReZ. .s 1 K /R'n/y /21, O,
Address
/IXSINS/1n z / .A9L CTR• /9/ 6 9A/y NY- (aa0Y
Death Certificate Filed District Number Register Number
City ov or Village (5C{625t/S/ARV S� c C'
Date / Cemetery or Crematory
❑Burial 04)— oe-.1O/2 //t/e!//eZv? R&176'7-45,R/ G11n
Address
®Cremation cy tiEEivt' 3G(R y Il/y (2$61
Date / Place Removed
Removal and/or Held
—• and/or Address
gHold
Q Date Point of
NElTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I11111111 Permit Issued to Registration Number
€=I a Name of Funeral Home /f719 S o/f Fuilt?',9 i a)'i _ O///7
1 Address
111111111 /e 6�O R6 S i•. FORT /4/11/_,, A/X /2P..J 7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ains described above a i dicated.
;- Date Issued �/0�/.�O/ a istrar of Vital Statistics /l =,3,
(signature)
1 District Number 5(c s Place 7"O leA/ o-f VG/� /f 81,612 /Vj/, (21 O 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- �
WDate of Disposition $'4'IZ. Place of Disposition 1'?/J/cv C riv-
2 (address)
iU
CC ti (section) �
/,/ dot umber) (grave number)
G Name of Sexton or Person in Charge f Premises r, � r t'wt
g (please print)
Signature Z,41,_ Title aft" rot
(over)
DOH-1555 (9/98)