Frederick Jr., Bernard # 712
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First,, � Middle L Sex
rn cd mes , --ed eri r, Tr- /a:,
Date of De, th / Age If Veteran of U.S. Arm or e�, _/ 7
1-e VVl at r 0 A d War or Dates 7 j L�
Place Death Hospital, Institution or
Z City, own r Village le " Street Address /6//e-e R�
w Manne Death ;� Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined❑Pending
0 Circumstances Investigation
W Medical Certifier me .__.�/ Title
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Address
d-. 3 S--/ccite Rre 7
decioceiy? , ,(i-nAe/ . -.
--.:,:„ Death "ficate Filed Dii rict Number Register Number
City, f or Village C�eS4v J�(p s "- 17
❑Burial Date 9 or Crematory -
❑Entombment / /01 7� 0/ 7 �r e 7 0-e c-e) 0/. Ce 7/e 0/vi--✓1
Address,
[ Cremation CitiCe GK-�r ,igi/ a21)--e —Ci'air/ Y/),‘V
Date Place Removed
Z ❑Removal and/or Held
9 and/or Address
F= Hold
ul
0 Date Point of
e5❑Transportation Shipment
—
G by Common Destination
Carrier
Disinterment Date ' Cemetery Address
❑Reinterment Date Cemetery Address
7 Permit Issued to Registration Number
Name of Funeral Home k ,) tupf..e mow
Address
1 ?VOL ST Ci-tarf.2 (WI�, lag
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
W.
FL: is hereby granted to dispose of the human remains es ib d above as indicated.
Date Issued ct---.,2 to— fl Registrar of Vital Statistics ((WO-c
(signatur
District Number S''6,5a Place ) 6 rk c.4 dZ veSf�✓
: I certify that the remains of the decedent identified above were disposed of inin accordance with this permit on:
p i 11111� Dispositioni ud C•n`v�
ILI Date of Disposition Place of , ✓ c.r
2 (address)
Ili
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 14,,,-1L SBA4 i t
2: (plettse print)
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Signature e[ Title _ CDe(nV1 A.
(over)
DOH-1555 (02/2004)