Heidrich, Donald NEW YORK STATE DEPARTMENT 9.F HEALTH
Vital Records Section Burial - Transit Permit
Name First -}} Middle ��p Last Sex
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Date Death Age If Veteran of U.S. Armed Forces,
--LD I 10 War or Dates
f•. Place of Death Hospital, Institution or
5 City . ow`. r Village )- LC)/ Street Address Coo m ou ohm m kg(
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
fJ Circumstances Investigation
ill Medical Certi � Name ��� �� Title
0
J Address
S0.1,r0t-ft a 4r in95
Death ificate Filed NDistrict N tuber Register Number
:: City, owl, r Village Hai L55 g
DBurial Date03 - JJ,^� meteJor�C"r'e�m ry �/I
[]Entombment ' U Z� �Q 1 t ne__ V I elk.) � ,�1 t(,��
Addres
,_`Cremation -_ __irl b
Date Plac Removed
Z Removal and/or Held
.12❑and/or Address
f- Hold
5 Date Point of
Q Transportation , Shipment
i3 by Common Destination
Carrier
`> Disinterment Date 1 Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registr``ation Number
Name of Funeral Home re- P 1ALY1/Jail - Q )hC , DOC_7-J(
Address 0 Yl u.rC) St C Lac arit >7 (f V140
Name of Funeral Firm aking Disposition or to Whom
1 �
Remains are Shipped, If Other than Above
Address
#t
w
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3-1(0 -1(o Registrar of Vital Statistics 1~' u4�� ,�'- 1--7ye t 2, y
(signature)
District Number 115:6& Place-1—C;„ .S)) O d ley
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 'Mg i A Place of Disposition ?of g,,, , C„„
(address)
in
CC (section) , (lot nuTker) (grave number)
gName of Sexton or Person in Charge of Premises [ _ t•jA
Z r, please print)
Signature d _ 7 Title afse
(over)
DOH-1555 (02/2004)