Mack, Robert R NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name F
Middle Last
Sex
....................................................:::,::::::::::::
eran U.S.Ar of med Forces
Date of Death Age ff Vet ,
War or Dates
.b:. P4...:.....z.�.4...4 :::::::::.:.:.::� �
. ....::::::::.:: .:.
Place of Death
Hospital Institution or
City,Town or Village Street Address
.........:.......::::::.........: .t1. .::. - 1: ::.::1.1
i�t�a�� Cause of Death
:.>.
t. ::::::::::::..::.:::.::.:::::::::.::::::::...... ...........::::::::: ..::::.cJ.n.:c.a. / . . :.�Pa. � ..a.. .._::...........:::::::..::::::......:.........:::::::.....::::::
;fll: Medical Certifier Name Title
......
Address
...........................:.::.:::::::::::....:.:::::::::::::.CV: ::. ::.::: ::::::::::::.:::::::....
Death Certificate Filed - 'District N ber::: Register Number
City,Town or Village 70wA)
Date Cemetery or Crematory
Burial '
::.............:.::...f ..:::...�:.,:::../... ...9... ):.:...........::::.7 !4 C�/....eu)......... rem a..: Q �u.rr1.:::..........
(Cremation
Address
:.:.:::::::.::::::::.... ..:u:...e........e....n....:3:b.c..�r. ..:.:.:::: t?::
....................................................:.::..
Zi Date Place Removed
❑ Removal and/or Held
and/or Hold ......:::::._::::............::::::::::::::::.::::::::::::::::::................:::::::,..........
Address
C? ::::::::::::: :::......:::::::::::,:.:::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::,:::::.:::.............................................................................................
G Date Point of
❑Transportation by Shipment
CommonCarrier .....................................................................................................................................................................................................
Destination
..........................................::...Date::::::..................................................... ...............................................................................................
......... ..
Disinterment Cemetery Address
..................
.............:::.
Reinterment ` Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm q(�Ej/c?TOitJ _ C'
::::::::::::............:::::......:::::::::.... ::......:.::._::::...:::::::::::::::::....::.......�r1...:.:...:. m,orr:::.::. .a.::::::::.::::.::::.:.:.: .:.::::::::::::.... . Q. .. :::::::::::::::::.:......
Address
E S
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 c? 90 Registrar of Vital Statistics
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 719 Place of Disposition //�{-/,E7kJ C/�.C%'l/9 /�/�/�
(address)
A
cn (section) (lot number) (grave number)
GI Name of Sexton gr Person i Charge of Pr misesUj (please print)
�
Signature Title
DOH-1555 (9/86)p 1 of 2(formerly VS-61)