Hensler, Jack I NEWYORK STATE DEPARTMENT of HEALTH Bllfld� - TrddSi PBrnllk
Bureau of Vote[Regards
Nmrc HM Middle Wn Sex
Adel HemmerMXe
ome MCeach AM NVertran M US Armed fine,.
0(Allso 0 RYw I WYa Mk,
F Xaceof CeaM Rootest losestinnar
w CM.Towna ViX QOXon Twm Sher"rtv lnl EEtlnwn Rlmmmd.5k,ow Twm,New YCM 12M
Manner a oaaln ®Naurelpnx pAalaem ❑I RAW ❑&Arch punaelermima El
cranm„arra, mmmWlinn
MMvzi[erNler Nacre mN
, seem
cess Ac M
Mares
N al Nm M Ae awmL aas, Igig la HamML New TM 1xBe]
RaIM14ndialefiea =NumAn RyMrXumtrr
C .Toem or Vi perypn lsN SrFa 5
p Bunal Oale Cemelen.CCm:xrixilh/Hame
❑bromhmem oddress n.w«crem.h.Y
Address
%peremaeml (sum.mmwry Tour.xme v,ir
pDowdon
op Removal oaX Ease Mmrttl
F anal, ananlr Held
is HOIa ]dares,
gp]ren, wm ThemmM
is by Comma sniymem
Cars, Namara"
❑ Rirmemwm Bare umeervAaemee
❑ umremwM Dole umeNn Alare„
hurrah looser to Re sYaNn Number
Nmeof Funerallbm, A1ar+rrax PeMerfurertl Hrme rat
AMMS
U00 MeinST WonenXwq.New YM 128M
Nwe M Fureral Fmr Matiry Oisp,Nm or to Whom
H. Ramams art Shiroad,N aheravn Above
S Address
Q
W
� PonnlWmn lw hereby gnMW rotlivpax of Ma Numxn ramelna EewMEatl NLow as lntliwNtl.
Wlelssued OL =20 paginrmol YnalAmisli[s 9��Cm vXy1 NN+^d^Xy*wd)
Rhm+/
Oinkl Number sew Vlae BMIm LondnR New Yak
worry NSlhe remains More hrekm ihmaN abve mere ai,pried M in amMarcawrh N.0 Fermhae
WOMMUIa Pwnun 4mw E.aMonPmrinn 1?f G'
i Auw
W ree, i'
r/ra L 4immmamwr
SWmemse.mn,Permnm ar.Xea ywn' �
w
Ul 1pm,a nu
sixnwre 4 rule
WH15551o2AWPIM2
Nblic Hwm Law see. 4145(2n) J 13 95 3
Receipt
Human remains of I delivered on . 24=
I
L/
Fneue:cmetwre RepmxminBbe tmenl name names on "p t
Mow Foncm Dmctm Reg.m License.# `�"