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Whitcomb, Roswell A Jr. NEW YORK STATE DEPARTMENT OF HEALTH Zv1 Vital Records Section ~ Burial - Transit Permit iti Name First Middle , . Last Sex Ro5rve)1 A-• a WNircorrj jf inadf Date of Deatii Age If Veteran of U.S. Armed Forces, 040412,0 2 3 90 War or Dates kot2 earl WGr i Place of Death Hospital, Institution or City, Town or Village $ R� ' (3&.5IN C 1 1'13 Street Address 3C1 rc+a G-c. WOSP r`sr 1 :iitManner of Death 'Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined Pending Circumstances Investigation fa id Medical Certifi Name le a Qar1 t<es,t <? l ` Address C `t r- .: a i 1 cvw-c -, ca l reW -Q ` (^ J r tr) S , ( JP Y(7 -� 1 2 6t7 ilig Death Certificate Filed 'istrict Numbe Register Number l City, Town or Village, & S j`I{, 1 S `i 50 1 El Burial Date Qemetery or Crematory o�`06I i•ne VI' F,4) CrP.rr c(4-of/y i] i„El Entombment Address i.?[ .Cremation o t)e e,n 5 Ov c. 1 N PIS) 1 ar'c Date Place Removed rir❑Removal and/or Held and/or Address ` Hold Date Point of Transportation Shipment Cby Common Destination Carrier [�Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address gik Permit Issued to Registration Number 'i: Name of Funeral Home W,I1 kt,„ -S . 6 U2 _P 4- So{`S F-v- c.( 14.4 0 Vic Z-7 iiiiiig Address »>: bDg NOft` 14 1/5,20cuz izo1 .5aca;o R SffifIs nil 12%66• Name of Funeral Firm Making Disposition or to o Whom Remains are Shipped, If Other than Above • - Address Cr CC Permission is hereby granted to dispose of the human remains-des dab as ated. Date Issued ©6 2,3 Registrar of Vital Statistics �}f♦ (signature III ' District Number 9 50 1 Place 5 > a.,(jQ;9 A S, N2,1 r,Is +n Y hi I certify th at the remains of the decedent identified aboe were disposed of in accordance with this permit on: ta Date of Disposition/-6.-ze z 3 Place of Disposition vvy, V r-osuciv (address) Ill to (section) (lot number i (grave number) Ci i Name of Sexton or Person in Charge , emises �_14�lsldl�D ©QC eas print) Al ::; Signature Title (over) DOH-1555 (02/2004) I Public Health Law Sec. 4145(2b) Receipt Human remains of - delivered on • , 20 1/4 Pine View Cemetery Representing the funeral home named on,blu ial permit Official Funeral Directors Reg.or License#