Heinrich Jr., George NEW YORK STATE DEPARTMENT OF HEALTH I ` - ` /6.2-
Vital Records Section Burial - Transit Permit
t=` Name First Q Middle Last, I Sex
Q � � � ein rich `fin-.. I Made, _
Date of Death Age If Veteran of U.S. Armed Force
l/3//13- (o 7 Dates j/f
j Place of Death C,Hospital- nstitution or
CitILIy,Town or Village (/eL1 Fa,1lf Street Address �. �S '� S
L3; Manner of Death Natural Cause 0 Accident Homicide 0 Suicide Undetermined n Pending
t Circumstances Investigation
la Medical Certifier Name r t, Title f
0 ,LI O cZ R_ - ek I ///d i / 3
Address 9 C
Certificate Filed District Number (7 Register Number . / 7
Cit own or Village ����s- �r�-LC<S ,_- -.-
7Z
Burlal Date Cemetery or rematory ` f li
2- 4, / 7 __ ,Jrr t;,
;❑Entombment Address
<` +( remation Q 0`0'1 CC_,n-- (1t4, Q UL2',-. L
Date i Place Removed
Removal
and/or Held
F- and/or Address
ID Hold
0 Date Point of
(15 Q Transportation Shipment
ES by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Date Cemetery Address
`_>El Reinterment
Permit Issued to Registration Number
Name of Funeral Home ca cas(le o.\ hoct- C t 1 0
Address
k% LekaH e-- - S. - t-,s k-:r 1 / IVNk 1Z. O
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tt
Permission is hereb granted to dispose of the human r mains described ove as ind cated
Date Issued • Registrar of Vital Statistics .P_2 07/
( ignature)
;;i: District Number5-zeo / Place c� -& �/y14I certify that the remains of the decedent identified above were disposed of in accord h this permit on:
2 /
lLI Date of Disposition 71011 Place of Disposition g L
a ,"Y"4taf:,.a.
2 (address)
fa
t11;
r (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ��r,,, ,,_ ��'"^��
(pl ase print)
ILA
Signature LalZ Title EPOniiiPt
(over)
DOH-1555 (02/2004)