Huenemann, Robert NEW YORK STATE DEPARTMENT OF HEALTH 44
Vital Records Section
Burial - Transit Permit
w. Name First Middle Last Sex
R O.�E T k_ R c E cu E rc\ \Nth& Pn R
Date of Death Age If V ran of U.S. Armed Forces,
}N , t ct J..0 i \ g 3 or Dates
#y- lace of Death Hospital, Institution or
City, Tewn of Village ( N S 4 u s Street Address CrLL N S -7A►_L S Nt~S CM L
0 Manner of DeathyNatural Cause Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
Circumstances Investigation
ui Medical Certifier Name Title
Address
10j- \7 K S'i, ) C L€ R A ) 11 l IsS"O I
Death Certificate Filed District Number fi t' Register Number
in City,- awn ef-Village ( LE S FA l_LS _ S. a,O / l[,
❑Burial Date Cremator
, Jo S0'�t \ i N E i G(..4) i \FET R.t t .1�'►�t_.
..:: 0 Entombment
Add Tess )
Cremation :4 \ U A K E.( . v U EE,iAs isc fa /-'r t a�O
tf-
Date Place Rremod
1 ❑Removal and/or Held
and/or Address
Hold
In
0. Date Point of
InCL Transportation • Shipment
ES by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Miz •
in 0Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 4-6 R5) ( tv E 1 I4 . 1-,-von €) 1(e..;C , - b 1 L 1-9
Address
9 0 ''),-N(vm.,--r-em unk S1,, LA KC GeoR.&c) '1") I a �s' Ls_
Name of Funeral Firm Making Disposition or to Whoa
Iii Remains are Shipped, If Other than Above •
• Address
is
W
• Permission is hereby granted to dispose of the huma remains described kbove as in icat9d.
Date Issued /1/O,, ! ,O//Registrar of Vital Statistics , e
/ (signature)
District Number ss'6 0/ Place a_... ... �l
I certify that the remains of the decedent identified above were disposed of in accords ''e with this permit on:
lit• Date of Disposition. JF u tbl?pi t Place of Disposition • l 'n r V ,r vJ C'�rr a r1 w--
(address)
LEI
CC (section) 1 (lot number) (grave number)
0
0 Name of Sexton or P rson in Charg f Premises b+rl,fr,(�f�t r J e"rat
r / please print)
Signature (/ � Title C IZFP?i-Tt1f.,
(over)
DOH-1555 (02/2004)