Seltzer, Charles NEW YORK STATE DEPARTMENT OF HEALTH 4 'it 3, 1
Vital Records Section Burial - Transit Permit
Name First Middle pst Sex
\r. 6. &1- z,Lr- Ma/e
Date of Death Age If Veteran of U.S. Armed Forces,
`7 - -ZO /I $ I War or Dates Iq`17 -/cp-/g
1— Place of Death Hospital, Institution or
City,`ow or Village �.D/1 Street Address ;_I/L/S 8c-fr_
W Manner of Deathoso Natura�C 1-j'ause 0 Accident 0 Homicide ❑Suicide ❑ Undetermined r-i❑Pending
Circumstances Investigation
W Medical Certifier Name Title
1--)ov�R idT�c %�� lS9%V C,o r-
r_oA�.
Address
3S o etc z I' ir-t- >ui Y 133(o o
gi Death_geOficate Filed District Number Register Number
City own. r Village )yL ,1.k g o?056, ra
❑Burial Date metery,/or Crematory
❑Entombment -7 1211 it l✓,4 L Y i o ! ill. -0-
Addres
!iiEii!!'; Cremation �L �
Date I ' lace Removed
go Removaland/or Held
r: a and/or __
F= Address
Hold
to
Date 'oint of
N ❑Transportation _ '-lent
0 by Common Destination
Carrier
m NE❑Disinterment DateCemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home t.li ik A.LiLd k . 4_,..Ac __, Do r i 9
Add:iiigress
( 7 ,Staff °fin Oka ilk - �-A { 1 d S�-1 c,
iql Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W. t
!'•?. Permission is hereby granted to dispose of the human re£ 4.&.L.?
ains described above as indicated.
ig Date Issued / Z!o I 1 Registrar of Vital Statistics
signature)
giii District Number 20 5 Place tO n O42 LO n 9 L.GL.41e.
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition °)i i I q Place of Disposition t r4U: ,,,/ Crywtilur u,-
(address)
111
cc (section) (lot number) (grave number)
Ci Name of Sexton or Person in Charge o Premises (1/07%,14,1- .9-41'Z (please print)
ill Signature - Title C12er<i+1e
(over)
DOH-1555 (02/2004)