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Moeller, Karl Ir NEW YORK STATE DEPARTMENT OF HEALTH 1 /I Vital Records Section Burial - Transit Permit Nam First Middle Last Sex FCi.r 1 14 . M ©wile— IlAQ 4() . Date of De h Age If Veteran of U.S. Armed Forces, 1 a 17 o�-Ln i Q 3 War or Dates Is._ (Cf�"� 1,.. Place of De/ e th Hospital, Instituti r Cit , Tows or Village�-�)Q�1S (-Cl l5utk— Street Address Pep3 1--a 115 1-fos,oi1a a Manner of Death l�l Natural Cause 0 Accident Homicide 0 Suicide Undetermined 0 Pending Iti �A� Circumstances Investigation W Medical Certifier n Name Title a l Ririe( AAAie `- Mci Address eV415 1-0 1 Ic) ti /Qeath Certificate Filed District Number Register Number 2 2 ;>;(Cit Town or Village C-�l,,eir)11 I I_`j 51oD I QL�- ['Burial Date Cyyetery or/Cremato jam, ❑Entombment 1 Z-Z O_ZD I 1 ' v-R V i e (.0 u� 1 I u 0,1 Addres : Cremation L{frt`If3bu r-b, Date . Place Removed Z Removal and/or Held E ❑and/or Address M Hold IA O Date Point of EL 0Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Re istration Number Name of Funeral Home�jr ir- fle al I y' %I y1 C, 1I Address Al- Chose h 5L Laicc Lu24. ; /l /284 Name of Funeral Firm Making Disposition or to Whom }. Remains are Shipped, If Other than Above 2Address CC ILI Permission is hereby granted to dispose of the human remains de crib d ab ve n icated. igi Date Issued 011,91)(e) Registrar of Vital Statistics � ' r� (signature) District Number 51c0 ` Place NI./ o le f 71s I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I LI Date of Disposition 12JZ.Lf//t�Place of Disposition ; j i e U (e /CN'/4. l e cy` / ( (address) til fa cc (section) lot number) (grave number) Name of Sexton or erso in Charge of Premises -i /iwvl Cwr,2G� <>he Signature , .t- r,�`'-' Title C-re mC. >Lo l ' (over) DOH-1555 (02/2004)