Paustian, Walter NEW YORK STATE DEPARTMENT OF HEALTH ' f " 5 -
Vital Records Section / Burial - Transit Permit
Name First addle Sex
Date or neat Age If Veteran of U.?pst
ed Forces,
8 1/ /(j .68 War or Dates 6S /9�z —/95—
If- Place of D ath Hospital, Institution or '� ,�L ,
City, Town or Village ti��Z�B u(,v/V Street Address � � Lam'\
ci Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined El Pending
W. Circumstances Investigation
W Medical Certifier_ Name Title
'1>��i'"-- i' 'A, /r e-b
��pQ _ / '°` d ess _
Death Certificate Filed Distric{Numb Register Number
City, Town or Village �'L j.Z^b��t/6_tl� /0-5 c•
❑Burial Date /� Cemetery or ematory �f/
['Entombment
/�L-1// � �'4/
Address
ErCremation c: Z1�' �—te�eV�/ /A V
Date / Place Removed
Z' Removal and/or Held
9❑and/or
Address
u1
Hold
O Date Point of
in Li Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home 4E/( '. / ��<< %/NL4( /fl d G)>/9
Address
LS /i'oo,i %9A X .• /287d
Name of Funeral Firm Making ISisposit�'on or to Whom
Remains are Shipped, If Other than Above
2 Address
it
tLI
"` Permission is hereby granted to dispose of the human ains scribed above as incl. ated.
Date Issued d/j p Registrar of Vital Statistic
(signature)
Mii District Number
i�� Place`—R4rn � Ali z���;��,�
I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on:
lit
• Date of Disposition Sl thb Place of Disposition gd....- 4,47,tr.---"
',. (address)
111
VI
CCG (section) (lot number) (grave number)
Name of Sexton or Person in Charg of Premises A.'` V
(ease print)
LuSignature Title ttTh -
(over)
DOH-1555 (02/2004)