Cing-Mars, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle ast Sex ®
� — i�rt��1 i�►tel�C.Q.�
Date of Death Ag If Veteran of U.S. Arme Forces,
3—`?9 7? War or Dates 19 IR -
Place of Death Hospital, Institution or
i Town or Village Street Address
Manner of Death Z Natural Cause Accident Homicide Suicide Undetermine Pending
Circumstances Investigation
Medical Certifier me Title
Address
Death Certificate Filed District Number Regi r Number
i Town or Village /O/ 1 16
Date 6 Cem tery or Crematory
:> El Burial to ' %use
®Cremation Addres
Date ce Removed
8❑Removal and/or Held
—• and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
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 C .
(signature)
District Number Place
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU
Date of Disposition — Place of Disposition )� �� 1J� (,� ��� /V) �, p►"
(address)
(section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises
z (please print) y
W Signature Title .AA PJQ \2
(over)
DOH-1555 (9/98)