Nusskern, Gustav e 1 tril
NEW YORK STATE DEPARTMENT OF HEALTH �„ p Burial Transit Permit
Records Section `
== ' Name First Middle t I Se
r
v Si IIU SSk. 6-'2,A : /Y�b'
:> Date of Death / Age I If Veteran of U.S. Armed Forces,
g q /7 1 93'- ( War o ti3 -Li (o
Place ath I Hospi Institution
5 City, ►own Village //0 2 t3 V ( Street Address )17 O1= L60 8 �' 1(31
Manner of Death'�Natural Cause D Accident n Homicide 0 Suicide Undetermined Q Pending
3
Circumstances Investigation
Lij• Medical Certifier Name pkt Ti'eg 1 L! i0 CI . 6 1-
Address
3 Z7 3 t
` Death icate Filed / 1 Distr-ct/Nu Regist Number
':-:: City Town Village 6 Urya- I `7",_ '�
-` 0 Burial 4 Data Cemetery Crematory )
❑Entombment
If / I.
/,J cf It )
- - Address- — - ---
`kremation QU i 6\ J 6 (3 u147 A77/
Date Place Removed '
0 C Removal and/or Held
and/or Address
Hold
•O 1 Date Point of
C T ransportation I Shipment
by Common ( Destination
Carrier
fiDisinterment Date Cemetery Address
E Reinterment j Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home -&•h �1�,z11 HOB�� C2,11 t_`
Address f�
t L-cl -\V-- .4- _ is :a`tu; 1 ; KI I-Z(6 C to
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
to
P,'. Permission is hereby granted to dispose of the human remains describ d b e as indicated.
Date-IIssued L-/-I//j/7 Registrar Wile{ Statistics
lI QLto'i2 t'— t (sign re)
District Number 1 Place ' 5( 0 j t Aj g ���
/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r Date of Disposition FI!l q/�/
l Place of Disposition t /,,4-ns etc!'a✓+
(address)
la
M (section) (lot number) (grave number)
C. j
n Name of Sexton or Person in Charge of Premises ! 4 r,itrhir itom l it
- please print)
Signature b j Title ( `P4� �1
(over)
DOH-1555 (02/2004)