Rhyn, Richard NEW YORK STATE DEPARTMENT OF HEALTH s v If L(7 Z
Vital Records Section Burial - Transit Permit
Name a
st Middle �L t Sex
nit
Date of Death Age 1 If Veteran of U.S. Arme orces,
9 J 1� I ) War or Dates
-- Place of II-ath Hospital, Institution or
ILICity ,twn r Village U j Street Address75077 R4e
a Mann • Reath aNatural Cause 0 Accident 0 Homicide 0 Suicide ri U termined �Pending
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Circumstances Investigation
La Medical Cert. ier Na Title
AI
Address ,
Death Certificate Filed District Nu Register Number
City, Town or Village 5 7t 3 / y-.-
< /OBurial Date Ce,�etery or Crematory
❑Entombment -/LiW -- f -, I/.cL&
Address
Cremation eA�44.. (2 cQ a? m-. /-- I 5° l
Date Place Removed
Z Removal and/or Held
2❑and/or Address
i Hold
CA
0 Date Point of
Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
LI Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home-rn 6 K�Q ...2. y op:::.?
Address
i 3 tiQ --/'4 =,g--v-A,,,,,-44.} tea-- , A , . ..s.-0,
Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
a Address
CC
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` Permission is hereby granted to dispose of the human remains described above as in icated.'7 Date Issued "/3-/A Registrar of Vital Statistics •Lt ' 1 1,14f/ /
ti
(signature)
District Number 5 75 2_- Place �i2t q b & ,/4,Y
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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LU Date of Disposition °-ft _, Place of Disposition R4 u) L -& kor i,^
2 (address)
ili
re (section) (! umber) (grave number)
0 19
Name of Sexton or Pers in Charge Premises 1"i ✓ �''^-d `
�r (p ease print)
1t Signature Title C e/vv 73,
(over)
DOH-1555 (02/2004)