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Meins, Robert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First id le Last Sex,f A �If� R6 .:.. ..... ...:-.. ...:... ...c, h k _ Date of De th Age If Veteran of U S Armed Forces .I )-j -5-Z War or Dates Place of eath Hospital, Institution or , City,Town or-Village (j- F jI Street Address r 115 HOS;teis'i;t.. Manner of Death �Natural Cause ❑ Accident Homicide Suicide Undetermined Pnding Circumstances Investigation LU Medical Cert ier NameTitle p At hi. d E !Jrf. 4 i© Est..... ... II Address (�'� y� / f .... V"to K ` S �(c.4 is: Death Certificate Filed / trict Number Register Number City,Town-e-Village *(C,j r `'1S ce-a I Date // V::..'Ce�j ,ry or Crerry ❑Burial .. ."'!: .... [�C Address Cremation z Date Place Removed 0; 0 Removal and/or Held t- and/or Hold ::..:................ Address CO a. Date Point of v) ['Transportation by Shipment ...... • Common Carrier Destination ❑ Disinterment Date Cemetery Ad ❑ Reinterment Date Cemetery Address Wii Permit Issued to Ji ! Registrraatioon/�Num r Name of Funeral Firm w A/Q/1... AI , tei i V1 fig �a/cif Ge:(. 3 Address ii 62 e KIT 5Y-- --lei-0-. i et iy\-, 1 )-i--/l t- Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above P Address :.:..:......:...:. ILL 11 iiiiiit Permission is hereby granted to dispose of the hu n re ins described above as indicated. 1----Date Issued 1----J` - 3 Registrar of Vital Statistics LV• P &,tLnjj (signature) 4, r District Number ,j l?/ Place i /deb%/' I certify that the remains of thedecedent identified above were dispos-f�in accordance with this permit,�it on:� Z Date of Disposition/V� ?3 Place of Disposition 1457/.//,E'14,�41 E7/,e/vl /0�11W 2, (address) w N CC (section) (lot number (grave number) O' `/� ��p Name of Sexton • Person i Charge of Premiss kJ9 Al/9�� Z ��:�f� (please print) r W Signature i" �� i� Title r,� / ��� 5 /71 DOH-1555 (10/89) p. 1 of 2 VS-61