Robideau, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section f , Burial - Transit Permit
Name (first/ Middle Last Sex
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iiiii Date of Death Age If Veteran of U.S. Armed Forces,
0/ a3 - a o ) P- ?3 War or Dates / sgg6 - / 9Y?
F Place of Death Hospital, Institution or
Z City, Town or Village ITce r hi,"e e 3 c,_ Street Address /7 os,,s 4 a d j` � 1 d o✓ iM.'P/v u ypyl1
Manner of Death Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
III Circumstances Investigation
ta Medical Certifier Name/ �'y� Title
0 e,"chil _ • l t(—I(to��'er
Address
!"0 R P c. e 11,A `X / c I ;G c d e rc ) c` /Ny'' / 31E3
iiiii Death Certificate Filed_ District Number Register Number
City, Town or Village i l'c c r✓ i e?-of)cam- i--S O y -S`
>< ['Burial Date / / C etery or Crematory
❑Entombment 0"//02V/ ` 0)- `/itie Oic/0 C"i, A Fly/'/
Address
jO Cremation ue0.e_e_iLLs bur J�.
'. Date ' Place Remo\Pei
Removal and/or Held
2 and/or Address
L
C
Hold
O Date Point of
to ❑Transportation Shipment
a by Common Destination
Carrier
?`❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to G Registration Number
`:< Name of Funeral HomeEd�A i-cl h, /Z// f Nei'( (f z- - CV-cI r
ip Address t�
INIA g- N)( ' 0 da-v
iligi Name of Funera Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
CC
ill
Permission is hereby ranted to dispose of the human remains described above as indicated.
Date Issued 0 :43 t 0-Registrar of Vital Statistics J /Y) y
��^ (signature)
District Number 15-6 Place 1 f'CO t a t r 05Al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition 1/1 4/t2- Place of Disposition .?�0 wr,rt6taun,
2 (address)
1r (section) (lotmber) (grave number)
• Name of Sexton or Person in Charge f Premises i 1,1, 0ce,r- J evoro({
Zr (please print)
• Signature �, /'"` Title a04Ffiot.
(over)
DOH-1555 (02/2004)