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VanValkenburg, Michael Joseph
NEW YGRX STATE DEPARTMENT OF HEALTH r Burial - Transit Permit Bureau of Vial Rename Name Firm Miaek last Sex mmN&Jw xVen vad mate ha" Lima Rg NV@mat A U.S.Rmretl Fasas onrzarzom mrm.. wrwoaea 1W71M() F Plae of Oman li IreiMmn or IN Firy,Town or V, Im Grinvinalicassm sweeteddres[ Bks Valry CervwbRWabVutius and Panama; a Mandrel NoMM1 ONaluralCww ActNorman E]suicih E]BMYnmisia �Nnaiig V GwmAms Inrcraigalbn Meaial Fenaler Name TMe 0 emxN Anon MO mare[[ 10421 Some ment?40.Grant Times,XwYg1211132 aatambed No Bar Re yMr Mumler Chat Tom s,VlAW GnnNM D e F_ ❑Bi Dust Xame❑Fmomnnwn m ©cammmn Gimagunrwm Mwram Wan and/or ww oh %xe lkwoml aaprxma µ:la Aadre[[ �Tranaaaation NamPUN°f erfummun Yi Came, estimation ❑oi[imem:m Rate �meervmen �RiMemrent om Camara Aida, hsmaissueam P:yskaYan Number Nam of Fusing Home MprurC a BAN Fuss Home ett]] mere: If rush +sC somewhat Van yore ezBY instant Funeral Firm Mating efstai sib Whom RemeiHe aresni Pea nomerman uaae mare:: PennleeNxr In lrarnEy pnnYE W Elnpoen aF the NumvH Werni tlwCNEetl Whew an lndlcaYtl. rAe Issued Y']1,203p pspjslnrAVaaHMAHivs Yw yLm<a emSSArY6»weuPy3yuf/ omrcl terms 67Y Nam Gnmint Mewrge I smiry than the remains of eaedemidemr aaWre seem mseni in accordance wil,At,Institute: WoolLiep[aon 111 J�_ Plae AoieFaei(on 1 n+mmwi =earl _ C 6.�a. XaneAYmbnar Rrunln Uwged Premixs Y s'E SA.I I SignaNre � Thle ®besi f WXa555(MM)Pt Ae 01397]- j4hrinin Public HeaAh Lew Sec. 4145(2b) Receipt remains at _—_- - -- -- delivered on _---- %w Yew CemtlaY Repascn fin g the(aenwl home amd on N l Pvnem Dveuon Reg. or License N— Official -