Yanker, Barbara •
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
't''Name 1 First r) Middle Last ( Sex
? i)k rc a t4 I/. k fz�L 1 5-EPL3o
t Date of Death Age If V eran of U.S.Armed Forc ,
l 1 (9 /1 Z c to War or D ,,J/a'
1= Place th Hospit , Institution 9� r /
W City Town o Village 0 v ge /J S Q (Nu/ Street Ad ress (,J ;/L"d v,�r Jr�L,'at i i 1 fir"t i
tl Manner of Deatl1Natural Cause Aent Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title 3
Address
it , e e3r- S—. TT Co " l ZcpLs
Death icate Filed District Nu r � 'C ister Number
Ci To r Village Q U PS r( 7- -1 I
Burial Date
Z./f zlL Cemete o Cremary
Entombment ii,J t.r V t
❑ sp
Address`
['Cremation Q v g?Zb� 0 Q 0 .JSQ
Date ' Place Removed' Ai
Z❑Removal and/or Held
and/or Address
Hold
d Date Point of
to Li Transportation Shipment
C by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Hoot nu cl , &ker 17-,inc,r cL k iAo y-c CO 1 3U
Address
II t_akyit}fie S . , Qucenlrk.fy , Nve Y(31-'1L t2sioL
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
a Address
ICC
t3 Permission is hereby granted to dispose of the human r mains described above as indicated.
Date Issued a I a-�- !xQ laRegistrar of Vital Statistics " q A--t1
--------- (signature)
District Number SU —1 Place ) O()____r_., 0 Z` C) -� ,
I certify that the remains of the decedent identified above were disposed of in accord ce with his permit on:
iZ
W. Date of Disposition 2/2 2/2 01 Place of Disposition Pine View Ceme to r
1R (address)
y Hudson Sec. 1 33 D 2
cc (section) (lot number) (grave number)
aName of Sexton or Pers "n Charge of Premises Michael Genier
Z 1 (please print)
ill
Signature `-- Title Superintendent
(over)
DOH-1555 (02/2004)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t(l Date of Disposition 11 /8/12 Place of Disposition Pine View Cemetery
a
tli (address)
tfi Erie 43 B 1
CC
Ct (section) (lot number) (grave number)
• Name of Sexton or Perso i harge of Premises Michael Genier
iti z (please print)
Signatures' , J\ -• Title Superintendent
(over)
DOH-1555 (02/2004)