Dorrough, Robert A NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Fi� Middle Last sex
6 f3e/2 r
............ -F...... ................. ........ ........... ..... ..... .....
Date of De th Age If Veteran of U.S.Armed Forces,
....... 1
f.4':. .................... War or Dates---- - . ...
............. ........
......... ......... ---"--- .................Place of D Hospital, Institution or
City,Town or Village(_, L/
(4 6,ks Street Address
............ ........ ..............Cause of Death
V!
Lf 12 4-f Cj C Iv c,,,71 A L
..........
. . ........ . ......
Medical Certifier Name Title
...................................... ........................ .............. .......... ........ ...... .................
Address
eLopft /VY P qp,(................ .............................Death Certificate Filed .......
District Number Register Numbedc_City,Town or Village 17 Y cq�� 6,4:e�6&7 U,�
Date CemeT or Crematory....... ❑Burial
.......... ........
Address
lozremation
)a
............... ..........0
... .......... ........
Date Place Removed
a E] Removal
and/or Hold
....... .......... ........... ........
................ .......... .......
and/or Hold'.
Address
It
0.�.......... ...... ------------------- ........... ....... ......... .......... ..... .............. ..... .........11 Date
. .................... .......... ............................... ........... ....... .. ............................. ............... .....
Point of
V E]Transportation by) Shipment
C3. Common Carrier ...... .....................
Destination
........... .......
Date Disinterment Cemetery Address
171
........... ....... ........
....... Date Cemetery Address
11 Reinterment
Permit Issued to Registration Number
Name of Funeral Firm CPkZL&V'1)
Address
....... Qins�
.................. w......A-..I.....I V
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 remains described above as indicated.
Date Issued Registrar of Vital Statistics A eu,� )/'1�0
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition —0 Place of Disposition /61/
(address)
tx
(section) (lot number) (grave number)
.0
Name of Sexton or erson in har ge of Premises
Z Pease print)
W
Signature Title
DOH-1555 (9/86)p 1 of 2(formerly VS-61)