Konrad, Ina NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
iiiiii Name First Site Middje Last
•
/Y4---/-0-44,.. ; �L
Date of Death Age €' If Veteran of U.S.Armed Forces,
ii 2 :-//L .�-7 War or Dates
Place of De th > Hospital, institution or . .:::::::
ik
441 City,Town or Village A-' ......... Street AddressL4-14,-) ,.),Li,r,--6-:e.- ...........
E Cause of Deaa /::::.:::::
e.c c..-c ,, `gym.tirvl 0 .. .
iii
Medical Certifier ame r Title
Address
/...
. ........::::::::
» Death Certificate•Filed District Nu r Register Number
City,Town or Village �,y f � l�.`f '2�/ S y�
Date Cemetery r Cremator
O Burial
p / Y
Address ,....
❑6r�iatio n /...--1-, A--61...A..... ,
z Date Place FiemovSd
C_o; ❑ Removal and/or Held
and/or Hold>:.::::::::::::::::::::::::.:::::::.:.::::::::::::::::.:..::::::::::::::::::.:::::;>:::::::::::.:::::::::::::::::::._......::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,::::::::::::::::::::::.............
:._::
Address
o. i Date Point of
Cl) ❑Transportation by`: Shipment
Common Carrier [
Destination
El Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to ( > Registra ion Number
It Name of Funeral Firm �-
Address
II"!.. 9'0 71 .............:........, ,---1-1 '76'G
#�*
Name of Funeral Firm Making Po m Dis sition or to Who tt f
Remains are Shipped, If Other than Above
...........................................................................................................
Address
Atli
0:
El Permission Is hereby granted to dispose of the dead h an remains de ribed above as indicated.
III Date Issued 7 f� Registrar of Vital Statistics ,-4-4 tt1, de
v.')/C J
/ (signature)
,i, District Number !� Ir.� Place � .1 /�r , r4'�/C/_e_L_v_,,
r
I certify that the remai s of the decedent identified above were disposed of in accordance withc this permit on:
w Date of Disposition V 7/Y7 Place of Disposition / / 'i e < ✓'e /h •'9' .Dr i�(1rvt
2 (address)
w
�' (section)` -- (lot number) (grave number)
O
p Name of Secton or P rson in Charge of Premises �J c,/ `/ —`r, /�C�£S —���.
(please print)
Signature c70 4,.. �- /4%-1j • Title 17,,'.;-.,:,'t /n c bi ,y f�
DOH-1555(9/86)p 1 of 2(formerly VS-61)
a :•