Mattern, Walter NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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AAA,/ t'st /474te.1 V/ A/elif,/
;1•:iil Date of Death Age If Veteran of U.S. Armed Forces,
. og —I ig -- 6.1 / F3 War or Dates G1
1 Place of Death . Hospital, Institution or . / a 1
:,. City co "br Villabiff-yeeris'hvi: tAl Street Address „q 7 LA/0 opriec-.4 e, la
Manner of Death Natural Cause fcident 0 Homicide 0 Suicide n Undetermined r-7 Pending
'Circumstances 'Investigation
Medical Certifier Name do/ , _.,.._ Title
10 \..1 Goo,"c-..,, AI 10
v ,i
Address . / V
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,..30. 17 Sro c.,,te\ittesoli 1
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n Death Certificate Filed DAi • urenber Re ister Number
City, Town or Village & -----)
Date Cemeteg or Crematocy/
:::::: Burial ;VSA frZ, /--/,`V? e ../ V QA".1 6r e4...
: Address
.... Cremation 2. -- Ro-o‘• t 64 121, AA
•••
,••••
••••• Date Place Removed
• g,El Removal and/or Held
"-land/or Address
rg Hold
Date Point of
fh. 0 Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
. .
...... rn Date Cemetery Address
u Reinterment
a Permit Issued to Registration Number
Name of Funeral Home fiat fait N ), Lew._ FJ,Joto-r, gy6-- on (:)
M Address /
1/ I_il-' en,4i677-6— C7-, 0 otsL.-,04 CS Ony Aly /2.4r-o V
Name of Funeral Fjrin Making Disposition or to Whom i -
IS Remains are Shipped, If Other than Above
Address
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Ul
Permission is hereb granted to dispose of the human r mains described ove as indicated.
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di Date Issue I Registrar of Vital Statistics YA...-..,_ q RA.,,,....„,
_.... (signature)
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District Numbet.P c M Place 1 0(...A....rN, C.q c LL.Di2..AnA:.)
::: I certify that the remains of the decedent identified above were disposed of in accor nce wi this permit on:
t
Date of Disposition 2/1 5/1 2 Place of Disposition Pine View Cemetery
a (address)
fa
co Mohican 74n 1
CC (section) (lot number) (grave number)
0 Name of Sexton or Person,in Charge of Premises Michael Genier
-a ,'
Z - (please print)
'4,,-, t .‘..4- f i ;,,,l -
LA W..-•...., -,
44 Signature Title Superintendent
- (over)
DOH-1555 (9/98)