Harris, Robbie ..,._ , • t IOW
NEW YORK STATE DEPARTMENT OF HEALTH ;•.
Vital Records Section t Burial - Transit Permit
Name First D Mid le L s I Sid
/`o 13e 16- i S //,dL
gi Date of Death ( 1 Age If Veteran of U.S. Armed Forces,
2/I l J f V .5I.. ..._ War or Dates UAH --.,yaw ,.)
p. Place • _E-,th Ho for(� it-kr
City Tow • Village ( U 7J�S Street Addre (�. c3
r A,f,c> .Sd
• in Manner of Death Natural Cause 0 Accent Street
de ❑Suicide ❑ Undetermined 111 Pending
Circumstances Investigation
Medical Certifier Name Title
Address
S�° g(Z- .\Q--- . (J ,-vFc /� /2,/�'d)
Death -•ificate Filed District Number Rd'gist Number
City, own or Village Q UbY.�I3 (.� 5(.57 aq
' Date Cemetery or Crematory
El Burial Z//iii//e /1,JcJ vi61--t)
�} Address
•:•' IL-Gremation Lb— } j ...)- --.AR c �
Date Place Removed /'
• 0�Removal and/or Held
rz and/or Address
r= Hold
tI)
Q i Date Point of
0❑Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiiiii Permit Issued to _ Registration Number
<: Name of Funeral Home I P-X�� f—),-,L 1j[�,y�L. 0030
Address C
Name of Funeral Fm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Z.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued al 11 av I? Registrar of Vital Statistics 4L.o - --4..) ,Q,Qo&.
it (signature)
li District Number 5( c 7 Place QV Q.cA s bvii
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F 'r e...,4L_
W Date of Disposition 217a hi Place of Disposition eau,
2 (address)
MI
CC (section) {lot numberr (grave number)
DName of Sexton or Person in Charge of Prem- es f�iy J --It
(please print)
Signature • Title OfillRr ._
- (over)
DOH-1555 (9/98)