Howerstein, William NEW YORK STATE DEPARTMENT OF HEALTH C,
Vital Records Section Burial - Transit Permit
mii Name First ` I MjeJdle Last , Sex /
iiiiR Date of Death / Age If Veteran of U.S. Armed Forces,
in I�/a�S /% 6 —7g War or Dates
Place of Death Hospital, Institution or
City, Town�itta Cv r•' ` Street Address
Manner of De� atfi Natural Cause ❑Accident Homicide Suicide Undetermined Pending
❑ ❑ ❑ ❑
Circumstances Investigation
Medical Certifier Name Title
e�a L Re, -f : l, M D
Addr s _ _ _ I •
_ Cam, 6�S-�:J.� i Ni 1D,`60
dil Death - sate Filed / r � � District Number `>"sS Register Number
3 CiowVillage C� 3
Date Cemetery or Cremator!//
❑Burial Lk( 2.YS�/ Ca `4 1c_/;�,..., 6cM-,- �
Address ,\
IN Cremation C Ke-e 71�. 0r ,!U-6:-a `rrf(
Date Ci Place Removed
g❑Removal and/or Held
and/or Address
a Hold
Date Point of
❑Transportation Shipment
5 by Common Destination
Carrier
:::;: ❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiiiii Permit Issued to " Registration Number
Name of Funeral Home c 1-�--_n 5 ..r� ,"\c/'.C N,Mc , -.) 00 K
II Address S41,e-C" 0^`N 4C (c)r, r Oa`6 ��
Name of Funeral Firm Making Disposition or to Whom /
'" Remains are Shipped, If Other than Above
Address
NI
iiiiiiiiii Permission is hereby granted to dispose of the human re described above a indicated.
ii:g Date Issued Ia/ �/6' Registrar of Vital Statistics
(sig ture)�l
' ' District Number LtSS- Place �r' 4 ',_
) !� I
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
6 Date of Disposition Z Z 9 /G Place of Disposition //'I a l), C(A) Cie O
2 (address) /
LU
U)
C (section) 3 (lot nu ber) (grave number)
0 Name of Sexton er in Charge of Premises L,.1 i�.✓i Oa ry?G G�e
: (please print) j
14 SignaturePL- Title G le1'+' -/Dr----
(over)
DOH-1555 (9/98)