Eichler, Walter NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial a Transit Permit
j Name First , 1 �/� Middle Last \ Sex i
1�J 1--i- yL r�� (; /V
`<` Date of Death Age If Vete an of U.S.Armed Forces,
' 0/14 8 War or Dates kniWIC
P e of Death � -ospit.', Institution or r-/
. Town or Village (J j i S la 1)S - eet Address Cr/-P/14 s r /
/
ei ► -nner of Death( Natural Cause 0 Accident ❑Homicide D Suicide El Undetermined �Pending
III Circumstances Investigation
ua Medical Certifier Name `t, S. R IO6 I . Title rn-p
l�l I .'11/ kikS
f v ' rAddressIOV q 10 ad -C1 • ra 1'J 11 \ ( 2 FO
th Certificate Filed rr `` DIstrtc bn Reg er
(City, Town or Village crk-) tG.`!>
❑Burial ! Date ' j Cemetery or remato
1l 1- r( vLe v❑Entombment, Address t ( f G
:::::'Cremation Q& t-(� 1 '�G1Yt c bT,c- ' MN 1 C�O 1(
Date Place Removed
C Removal and/or Held
and/or I Address
Hold
CO
0 Date Point of
pi-i. Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
[]Reinterment Date I Cemetery Address
;' Permit Issued to Registration Number
Name of Funeral Home X\ \(X ;,e_ct \ HD S`il Ct t ?,L
Address
i. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
111
Permission is hereby ranted to dispose of the humari�emain describe above as ndica ed.
Date Issued O7 +( (7 Registrar of Vital S tistics (Jr,,, „..,--) j
( Rature)
District Number / Place re.c_- �
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
DA Date of Disposition 1112.1 f) Place of Disposition �mtU✓ �'r..n e(�-
2 (address)
tr (section) /'(lot number) (grave number)
Name of Sexton or Person in Charge o Premises `�jr �� � �1r�
Z. (pie-*-e print)
i
Signature t 'f"._ Title ( /
(over)
-
DOH-1555 (02/2004)