Bayer, Theodore NEW YORK STATE DEPARTMENT OF HEALTH 9
Vital Records Section Burial - Transit Permit
>_ Name First � �e� V Middle Last� �— I Sexes V
- Date of Death I Age I If Veteran of U.S. Armed Fords. /yam
tig 2 / 6 1 )9 j Q 9 ! War or Dat- S
' Place •" s eath An_
IHospita.•;stitutio F.r
City, ow or Village q bc.7 i Street A (A) k�7,n1 cs
_1 Man ' `'Death G. Natural Caus�Q Accident ❑Homicide Suicide fl Undetermined J Pending
111 Circumstances Investigation
, . Medical Certifier Name M i Title
Address
c/ (-6 c-74- Ceng /1.i 0 c6 a-,
Death C c'icate Filed I District Number - I RegisterrNumber
II Cit . ow o Village Gi L(V i -75o 1. ►J
Date b6 - i Cemetery or Cremato
_:: ❑Burial �� i P/A.) Vt& - )
j Address ;1-
i::Cremation LA6l/6 d�-�(1[�(� C\) J -n.) S �'J, ��Date _ Place Removed /
2 —Removal and/or Held
—and/or ' Address
Hold
Date _ ? Point of
ftn Transportation. Shipment
a by Common Destination -
Carrier
::: r-i Disinterment Date i Cemetery Address
3 t
Reinterment F Date ; Cemetery Address
- - E
Permit Issued to l Registration Number
Name of Funeral Home_ , _ . _ �'i:;l•'_ _r�,-)z:T,:� i�%c2_� 1 Oil<50
Address r
L f 13-'LTi'i✓ \e (4r'u- . S� a L<<L /`�i / /Lc3 o `I .
Name of Funeral Fim Making Disposition or to Whom J ' f " -
Remains are Shipped. If Other than Above
Address -
`>_, Permission is hereby granted to dispose of the human remains described above as indicated,
Date Issued 'a)/(4 /-7 Registrar of Vital Statistics Skelatkirliti-E-wk/
iiiIN (signature)
Distract Number S-7Su Place GAlit (ei i1/4)y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 2/2(Ij) Place of Disposition CllujP. arnitior',wti
2 (address)
I1
U)
(section) jot number) (grave number) •
0 Name of Sexton or Person-in Charge of Premises . lr„ �✓ S�,,t�
/ (please print)
l- Signature Ill Title aCElnitillt
- (over)
DOH-1555 (9/98)