Mesch, Robert NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section .. - • Burial - Transit Permit
iii Name Firsts� eta Middle Last / Sex 14
Date of Death Age If Veteran of U.S.Armed Forces,
War or Dates
. .... ....:.:........ .
o:..b
z Place of Death ,r' Hospital, Institution or
UJ City, ow .r Village L.a. Street Address ] `` 1 ,,((ff_,,(
IP Manner of Death ;t om} .::. ..... i_i G l.!i. . ..I / ....
Natural Cause ED 4e'6ident Ei Homicide 0 Suicide 0 Undetermined ri Pendin6
1,11
Circumstances Investigation
W Medical Certifier Name Title
Address
Pi!. ./..ea .Ae.. .N.S7.-t: Q. is .ltc /1/ ./;e812 /
Death Certificate Filed J /� District Number , Register Number
City ow r Village .t. /P_ ('a�0 p J SKS-/ oC
Date Cemetery or Crematory
❑Burial -^
C.2..-c 3 -. d f i. .. . e..-fA.
Address cad:.:::: C'i.:.�! :. Y� .... :..::..:..
Cremation G
z Date • Place emoved
O 0 Removal and/or Held
F- and/or Hold
Address
0 ...
Date Point of
cn 0 Transportation by
p Common Carrier Shipment
Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
giii Permit Issued to /�f� /� Registration Number
Name of Funeral Firm...' y117rt.. .0. �k . ....:.,, ..._01/30
Address y........ .j/.::: .
1 ti ZGI--(Q., ..e.le."-.5Y.fte.±.. ' /1//;/ / Fe7 V
Name of Funeral Firm Nfakfng Disposition or to Who�i
Remains are Shipped, If Other than Above
Address
Iti
Permission is hereby granted to dispose of the human remains de cribed above
's as indicated.
Date Issued a l Z Registrar of Vital Statistics e;,�(_. k-\701"''�,"
nature)
District Number 0..0 Place E A tj .j ,Z ,
-kit
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
W Date of Disposition 4"iL-1 V -t'o..G
Place of Disposition Vrx.J Ci'e►►,r,{od14
2 (address)
Ell
rn
c (section) (lot number) (grave number)
O
p Name of Sexton or Pers n in Charge of remises AJ pvir(ffr.'
W (please print) _
Signature Title C1l iVI '-t -
DOH-1555 (10/89) p. 1 of 2 VS-61