Kastelansky, Rudolph NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics - Vital Records Section
Name First Middl L t Se
;> Date of Death / Age If Veteran of U.S. med Forces
— J War or Dates r
Place of Death Hospital, Institution or �,, '`] --
City Town or Village ' ° f 3`kc`) Street Address �l-a , "` N-, �V t z,(4
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Cause of Death cri_evvizete
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Medical Certifier Nam Title
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Address i- i/ (gip,,,,.., A..,
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Death Certificate Filed y�� P District NumberR iste camber
City,Town or Village , )'71� �- C0 / 1
Date CCemeteryCremator
❑Burial l y l/ ? ......._ -t/=C c :� tzA._k u.
[c�.6remation Address /
Z Date Plac emo d
O ❑ Removal and/or Held
H. and/or Hold ,.........:..:......... ::...: ...
Address _..:.::: .. ::::.. .......... :: _...:..... ..........:.......:.
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....
CI. Date Point of
(n ❑Transportation by Shipment
p Common Carrier ......:.....
Destination
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❑ Disinterment
Date Cemetery Address............:.......:.....
❑ Reinterment
Date Cemetery Address
Nii Permit Issued to 72) Registration Number
.....Name of Funeral Firm �.c .L- -z,.-.4,. r..... '6 . C C X.3...
Address 'TO lam!/ h� �
,, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
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Address
Permission is hereby granted to dispose of the dead human mains describ d above as indicated.
tigi /
Date Issued /O/)'/'7 Registrar of Vital Statistics t�- 1,. y • v 7
iiimi (signature)
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District Number 3 b Q / Place �, 7AL.A.,:_i .., G'`•?� /
I certify that the remains of the decedent identified above were disposed
disposed of in accordance with this permit on:
Date of Disposition!Yok/ti 7 Place of Disposition Alf)e. Cce_,n cc.fo r• t t�7i✓ (� (.."„¢----o b /.
2 (address) 0
uJ
O (section) (lot number) (grave number)
d Name of Secton or P n in Charge f Premises jJi✓ i&a
Z' / (please print) _ /
W Signature (,L. '� Title : f'
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DOH-1555(9/86)p 1 of 2(formerly VS-61)