Kohaut, Louis NEW YORK STATE DEPARTMENT OF HEALTH 4t lZt
Vital Records Section Burial - Transit Permit
Name ,First Middle Last Sex
�.0(AZ -Po deer osLp1 1-(o hayr m
Date of Death Age If Veteran of U.S. Armed Forces,
id- - 19 - a.o // Co g War or Dates 1'J 6
14 Place of Death Hospital, Institution or
ii City, Town or Village ' i c c u (f p Ira 5 c�- Street Address /710..se5 L oc.Iti 5TG.) Psi 0p,'/d (
Manner of Death Ijatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
iit Medical Certifier Napap , Title
O. 1(1 Q f f 1 Stv fv Pi PI 1J -
Address
/0it tWt(.46 r Sfi,- c* `�/ a,oK) 6,. /a 1 a Y3
NI Death Certificate Filed District Nurdbe. / Register�Nu ber
City, Town or Village ; co d e r-0 9 a- �!
❑Burial Date coimetery or Cre atory
❑Entombment 1 - g.( - go ii (T 1�1C V/Q& �1^e�/►?a je1^�/
Address
iiiii Pit remation G V e -s ..,A u rr y /V 7'
Date !Place Removed
gEl❑Removal and/or Held
and/or Address
it Hold
Ca:
Date Point of •
l- Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
•
❑Reinterment Date Cemetery Address
Permit Issued to • C Registration Number
Name of Funeral Home ecl`u�P r ct Is ie-4 r i m e ra( J1'o"i d 0 3 1 g
Address
0C,11k-001 4Aye- N-r ids e14
im Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
to
Permission is hereby granted to dispose of the human re ' s describe, abovt-as indicated.
Date Issued /(X/ao/ad I Registrar of Vital Statistics t )) O c, O.
. '. \\pi-) '"ems
( (si tore)
District Number s Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k''"
to Date of Disposition OecL11 lop( Place of Disposition Prak1 Crc`(0l�
2 i (address)
L
W
CC (section) (lot number . (grave number)
ci Name of Sexton or Per on in Charge f Premises lC *Gflc Je*Tat
2 (please print)
Signature17 Title CQIEArid(L
(over)
DOH-1555 (02/2004)