Kleeman, Alfred NEW YORK STATE DEPARTMENT OF-HEALTH [ `g
Vital Records Section A, Burial - Transit Permit
Name First Middle Last S
ne-F Re-tO F , l< t�,1la,i �b-
_< Date of Deat Age IIf Veteran of U.S. Armed Forces.
G ��li� q� i . . wk a
Dates
ce of Death jam" 1 i 'spit• nstitution r
City own or Village Q L 1�NS ' e-�,(,s r Street Address (t iyAS 1 S
anner of Death in Natural Cause 0 Accident 0 Homicide ❑Suicide fl Undetermined El❑Pending
Circumstances Investigation
Medical Certifier Name ^r Title
Address
tau rE rto Q mrr ?ttr'JJ r ► 2ev/
Death Certificate Filed ( District Number Register Num?
illi er own or Village V ,E;'J.( S Fett,s 5601 i. 3/,5
i Date i Cemetery or remator fr
CBurial { (,� l2l // 4 I ,Jer V/b'L.)
Address ��
remation, t.) AIG - 4 ' 0 L3 J A$ g V Al -
l Date _ j Place Removed /'
❑Removal I and/or Held
-- and/or Address
Hold
0 ` Date Point of
1 n Transportation,j Shipment
ES by Common Destination -
Carrier
Disinterment Date ! Cemetery Address
[�Reinterment Date Cemetery Address
IIPermit Issued to I Registration Number
€, Name of Funeral Home _ _ _ - 894 nar ( 04//30
Address
Name of Funeral Firm Making Dispositio or to Whom - ' e ' -
( Remains are Shipped. If Other than Above
:g Address -
311
_` : Permission is hereby granted to dispose of the human ains described a ye as indic ted
la Date Issued 6/0 ` _ Registrar of Vital Statistics ___
(sign ure -,
District Number n/(06 / Place C
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
W Date of Disposition �f zi(I(, Place of Disposition !l,MOg i Ci taf i(..---
2 (address)
ILI
th
C (section) kflot umber) (grave number) •
0 Name of Sexton or Person-in Charge of Premises Sobiratf
Z 1 (please print)
4 Signature Title _ (I2‘M i2
- (over)
DOH-1555 (9/98)