Stehlin, Gregory NEW YORK STATE DEPARTMENT OF HEALTH VS
Vital Records Section Burial - Transit Permit
Nine M P��F��irst Middle + Last Sex ��
Date of uaatthr13 Age If Veteran of U.S. Armed Forces,
0 0-- 1p -) to V( War or Dates -Q 5
1- Place of Death — Hospital, Instituti r
Z (ity'Town or Village CD (Cr)S -I (VI 5 Street Address Ity)� a. L 15 k s j 1
0 Manner of Death ,a Natural Cause Accident Homicide Suicide undetermined P�nding
Circumstances Investigation
Ili Medical Certifier Name Title
0 JC(.1rY\QS MUf i\,46
Address
D ath Certificate Filed l District Number Register Number
:. (C Town or Village G fie,(S t a b s 6 1
❑Burial Date geiverery 1 '--53 - ) CO )iv.. t mat�oa ilkiCtilD of
0 Entombment
Addr-±
tACremation r L�Q.Rsbu.
Date J Place Removed
Z❑Removal and/or Held
and/or Address
f'"'R Hold
CA
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to RVl_QJ?kk
Registration Number
Nameof Funeral Home Mr 1UvQ )VI L. ® 1 199
Address 1.03 Vl 3D I nd t& A 1 cU Q MI 1662
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
t:LI
C Permission is h r by granted to dispose of the human remains described above as indicated.
Date Issued !I )(o Registrar of Vital Statistics k./.) ° Q-
(signat~
District Number (�d) Place C t' " ci G )eps ,15
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
u Date of Disposition jI/4 Place of Disposition 4 ,.,J 6 oa✓
2 (address)
Il
U)
CC (section) Al(lot number)( (grave number)
ti Name of Sexton or Person in Charge of Premises �+r, J,i"f
,2 (pl ase print)
r! Signature a ....17 Title 645 Atoe
(over)
DOH-1555 (02/2004)