Reinach, Daniel 4 I/ 10..E
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First i ' dle s96
EiA) i tre- g-oz. (c.er L 61 A)/ (h--
Date of Death Age If Veteran of U.S.Armed Forces,
Z (-1 A7 i `7 f WWta[Qr Dates6,1 (o y-J 9 7 0
Place of Death (HospitaiDnstitution o
( ity)own or Village ��t ,-)s Fe-u c Street Address L J i Ferz-LS
1o(anner of Death AI Natural Cause []Accident j Homicide (l Suicide Undetermined �Pending
ILI Circumstances Investigation
la Medical Certifier Name A/ Title A
Q / /ik-r-hi--,-,7„) UA9-12._ u ti L--is6-
Address C(0 2 Pen./c Er. Gt' .• /`',oz.c..,3 A 12<ra/
D h Certificate Filed District Numb � , " Re, ster Number
Ci own or Village (.d'..•r S f Pitt t �•j;
Burial Date 7 Cemetery o remato ( r -\..,3
2✓ 1 /, (.0 �. v
[]Entombment Address
(jo7
;;_::Cremation Ul�} t r'/
�u 1 �,✓ a
Date Place Removed
Z n Removal and/or Held
and/or Address
g Hold
Date Point of
Q Transportation I Shipment
5 by Common Destination
Carrier
0 Disinterment 1 Date Cemetery Address
n Reinterment I
Date I Cemetery Address
_- Permit issued to �} I Registration Number
<< Name of Funeral Home L .�'\E t-- ;�L:t \ -\O*-C- C-,k\ �m C
Address �,: _ 1 . li
Name of Funeral Firm Making Disposition or to Whom
1 ,_ Remains are Shipped, If Other than Above
Address
i
Lit
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Z-I Z 1 1 7 Registrar of Vital Statistics
(signatureV/e
;: District Number S G Q 1 Place 6 � s- , \ \ s Ak) y,
i certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition "f;11'7 Place of Disposition Pm V44 64'►n4iorh;-
2 (address)
Isil
E, (section) A(1,1ot number) (grave number)
0:CI Name of Sexton or Person in Charge of Pr mises �^1` �J t"^(
(p ase print)
. ( 1 .r- Title (1Em21f,
.. Signature
(over)
-
DOH-1555 (02/2004)