Fleisher, Alan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section , 1_ Burial - Transit Perm
.. Name First ) „ Middle Lasti Sex
illiiiill A.L- 1> f L e S�er i"uLe.
pE Date of Death Age If Veteran of U.S. Armed Forces,
e f• a$ ',oo 6 6 War or Dates
Place of h Hospital, Institution or
City own illage 1�a�le Street Address
t Ma o Death Nat�'tral Cause Accident Homicide 0 Suicide �Undetermined Pending
® Circumstances Investigation
Medical Certifiertil Nme Title
Addr ss
`; I 'a(,v S,,..-f-L J giiijj C..)r , . 3J 1 D. -7
?' Death Certificate Filed listrict Numbed Register Number
1, City' owri Village t ) GAte 4f-S6S "f`
Date 1 Cemetery orematory /
CBurial 2 ,.,c v:c ., C.C.A.440t:...�
L.r� Addre
Cremation k c n„y l U,r ije,, /oil
Date (J ' Place Removed
O ❑Removal and/or Held
and/or Address
Fk Hold
Q Date Point of
N El Transportation , Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiii Permit Issued to / Registration Number
Name of Funeral Home c h S 'v+0 rc a r-( e) --LC - O a s 3
<iiii Address '7 /
,t•A.,,,, Aw e. 6,- ,*,4__. A.1 ,--: L„,),s '..)..)_
Name of Funeral Firm Making Disposition or to Whom
"" Remains are Shipped, If Other than Above
404 Address
tg
f4
Ci;
Permission is hereby/granted to dispose of the human rem ns described above as: dicated.
III Date Issued �� 1bG Registrar of Vital Statistics �,�i o (�
�,+ (signature)
11 District Number mil''S Sb Place /a �..s- /`l.x.- I
/),, /
iiiiiii
I certifythat the remains of the decedent identified above were disposed of accordance with this permit on:
W Date of Disposition q lac)/O!o Place of Disposition etwhew Cro.,4 or t�..
(address)
LU
N
CC (section) / (I number) (grave number)
0 Name of Sexton or Person in Charge of Premises C. k r, s 5e h ne t,
, (please print)
L l Signature (1"1�""° Title 4'Gm -Gr
(over)
DOH-1555 (9/98)