Johannes, Richard -tEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
f Name First a` C _ „ Middle Last( rdIV � Sex_ _
Date of Death Age If Veteran of U.S. Armed Forces, M
1 3 i '/a- OD War or Dates ----'
). Place of Death Hospital, Institution or srt j City, Town or Village Street Address
0 Manner of De atural Caus ❑Accident ❑Homicide ❑Suicide ❑Undetermine ❑Pending
ill Circumstances Investigation
la Medical Ce fier ame Title
S GOVA.3 k -n Gin..
Address
( i c , St.t2t.P OW—Q.-
Death Certificate Filed District Number Regist ber
City, Town or Village CA .�Nufn 9co,
urial Date U Cemete Crematory
(QCi (d- )'(t Q \Poc.)) CUYI •
iim❑Entombment Address
'> ❑Cremation g (,t„QQX143�c�t�y
Date Placel3emove`d
❑Removal and/or Held
and/or Address
It Hold
CA
Date Point of
P❑
Transportation Shipment
G by Common Destination .
giii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iliiii Permit Issued to Registration Number
<> Name of Funeral Home £ S C .4 014-I,43
>' Address
5.3 QUct)oX R iz w u
Name of Funeral Firm Making Disposition or to Whom C
• Remains are Shipped, If Other than Above
;' Address
2
Ili
P' Permission is hereby granted to dispose of the human remains described a ove as indicated.
Date Issued q I 1 i . Registrar of Vital Statistics `-/'nLQ„,v _ pl'
(signature) EM
District Number iirer Place G.1-6/ -flow
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
9/1 0/1 2 Pine View Cemetery
ill• Date of Disposition Place of Disposition
2 (address)
tO ilk Hudson Sec. 1 32 E 1
CC (section) (lot number) (grave number)
Name of Sexton or Person incharge of Premises Michael Genies
2 OpNic2.0) (please print)
Signature
LJA V Title Superintendent
iini
(over)
DOH-1555 (02/2004)