Wiesner, Wilfried NEW YORK STATE DEPARTMENT OF HEALTH r ) (12_
Vital Records Section Burial - Transit Permit
Name First 'W i l (�-_ I e _' Middle Last Sex H
ni.i
>= Date of Death ? Q Age If Veteran of U.S. Armed Forces, r
CI-Z4-2.01kD gZ War or Dates
et
. Place of Death Hospit. nstitutio or T S�"�� l
W Ci Tow or Village Q peens ' `/ Street Address
ta Manner of Deatt�rl�1 Natural Cause Accident Homicide Suicide Undetermined Pending
it fy:. Circumstances Investigation
W Medical Certifier Name Title
0 3( -zc�xxre. '( Iood Physicio
Address i 52, Sher ri-Na '1 Ave.)QLA00.4obU�Jl4 ) ILN I2 WLI
Death -a ificate Filed Qiltrict N W�e/ > Rels i r lumber
City, ow •r Village c... :e2.r sbl 1
+DBurial Date q-Z� -2�I�o Cemetery oematory
•
vine, U
❑Entombment Address
►.1 Cremation CA. --R ,) Q u 49.A13b t UI.�.J� ,, 1 L 0 Li
Date Place-Removed ce emoved eJ
Z Removal and/or Held
D❑and/or Address
N Hold
0 Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to f-� Registration Number
'<` Name of Funeral Home ..\4 c 1-� t rA\ Ho�t. t t-0
Address �V;_ i ` IN 1Zhc`1
Name of Funeral Firm Making Disposition or to Whom
r Remains are Shipped, If Other than Above
,2 Address
te
Iti
fl" Permission is hereby granted to dispose of the human remains described a ove as indicated.
Date Issue\(4c t \ (p Registrar of Vital Statistics 1� i�
(signature)
District Numbe Place , ....,_
« I certify that the remains of the decedent identified above were disposed of in accorda i ce with is permit on:
ilt Date of Disposition q r jg bbiz, Place of Disposition .gntkiltw itmatOrt t1.
2 (address)
ILI
fa
it (section) a
(Iot number) (grave number)
tz Name of Sexton or Person in Char of Premises ` tease print)
z + P )
LC Title c fMl`1�K.
Signature ' )
(over)
-
DOH-1555 (02/2004)