Pohl, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
lig Name Fist Wfiddle Lastroil L. Sex
?<»_: Date of Death f : Age ;; if Veteran of U.S.Armed Forces,
,:ii c-' ` War or Dates
Place of Death Hospital, Institution or
w City,Towca-or Wrap ELL ' Street Address s [sS
Cause of Death 1
Ail Medical Certifier _blame Title
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ddress
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iz = Death Certificate Filed District Number Register Number
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Date / Ce ry or Crematory
El Burial P j
is
jmation
Address .. ... .......... .............................
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>. Date : Place Removed
..,.: ❑ Removal ii and/or Held
_. and/or Hold .:...........::::.::,:..:...:.::.:::::...::::::::.::::::.::::::.::::::.::::::::::::::;;:.:::::::::::::.:::::::::::::::::.::::::.::::::.::::::.:::.::::::.::::::.::::::,::::::.::::::.::::::::::.::::::.::::::.::::.:.::::::.:::.::.:::.::
Address
:
11 Date ' Point of
vr.: ❑Transportation by'.
Shipment
G Common Carrier
:: Destination
:...... ..... ......................::........................ :...:...........
❑ Disinterment Date : Cemetery Address
El Reinterment Date Cemetery Address
Mi Permit Issued to Registration Num er
� zName of Funeral Firm51-4 G.-- 2
;;N Address ....
j. Name of Funeral Firm Making Disposition or to Whom V /
e*-:,,ii Remains are Shipped, If Other than Above .......
QG Address
Permission is hereby g anted to dispose of the dea Ifman rem ns scribed. ove as indicated.
Ni Date Issued 7 li �� Registrar of Vital Statistics '_rc-
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(sign re)
District Number _ l 0/ Place ,� % � / ,/mod!%
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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tZ• Date of Disposition 7�/C3 f fr'7 Place of Disposition { ' rt C,c e�n i-
(address)
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CC (section)( ) (lot number) (grave number)
Q —p Name of Secton or Person in Charge of Premises c ---12 clef 4 r . c S j (
Z ` (please print)
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Signature 6 ` Title �-c.! 'c • ex C ` r G-
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DOH- 1555 (9/86)p 1 of 2(formerly VS-61)