Holz, Bernard NEIW YG K STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First ,� Middle , fast S ,62,E
.� 1-t_m 13-/t-3 -�ii-om f s f zj L 2_ /` �'
Date of Death I Age If Veteran of U.S. Armed Forces,
rf l( /1/ i ?9y n$ War or Dates 0 l f,
1- a of Death Hospita�, Institution or
l., own or Village �t! ",-)-S Flint S S�Address c.6-,..).5 / —ez.LS
1p Manner of Death 0Natural Cause 0 Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title '
CI SCt>TY r316 Srr'T"t,. /1,iJ "
Address nn ``JJ
i nO rAr2k S r., ahms f lls /V /p?2,/
ClCertificate Filed District Number j Regist�jr {nber
own or Village c,U`>, Fes,S 1 / / .
Burial Date Cemete :): r1i 6—
❑Entombment Address �
OCremation L. V L\ r , 06Lr,.. .xia uytAAi
.
Date { Place Removed / r
Z Removal j and/or Held
9-D and/or Address •
It Hold
IA 0 Date Point of
Q Transportation 4 Shipment
0 by Common Destination
• Carrier _ .
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home MG,/narci -b. - .1:er FunCcGi j;ry_ I 01 1 L1G
Address
II Ric yQ. -e s. , &u,cc_nSoury , Ni e v.s Jor L 12 c30`--1
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above .'
2 Address
Z. Permission is hereby ranted to dispose of the human remains 4j -i'
ribs ove ' dicated.
Date Issued Q`ff o2p%/ Registrar of Vital Statistics -G`L
(signature)
District Number J&o/ Place �7e /j1, /17
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4/4/11 Place of Disposition Pine View Cemetery
12 (address)
fil Hudson Sec. 1 18 B 1
(section) (lot number) (grave number)
p-. Name of Sexton or Person in Charge of Premises Michael Genier
ti (please print)
Signature-ri)N4.4iZ-6-,Q 53 . Title
Superintendent
(over)
DOH-1555 (02/2004)