Beyerbach, George , ., i 6 31
NEW YORK STATE DEPARTMENT OF HEALTH t Burial m Transit Permit
Vital Records Section
Name First Middle,.,._. Last { Sex,
0e rr3e_ JarneS Fore
1
Date of Death �J Age 1 If Veteran of U.S. Armed Forces, 1 A � —
1 Q
Ock \c \2o1� °k\ I War or Dates
Li-CP
Place Bath Hospital, Institution or CC
�
City. Tow r Village ace ut'-1 )(Street Address 14 CCW\a-cv t. Dr; v
e i Manner of Death (Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined n Pending
Lt1 ! � Circumstances Investigation
ll Medical Certifier Name -1_10Title
Address
:1.: ki I & Oct/
Death Certificate Filed D ict Nqm err 1 Re r`Number
City awn r Village Filed,,,,
r \o`�'r� , ,257-1
❑Burial 1 Date Cemetery or Crematory
1 1001 aoAu, ohm v'tom Crcrnai-cry
❑Entombment Addr s n
Cremation v �\leo r' (40►Lk C�,}eQ,rS`o u r yy 1 NY. 17.fl o g
1 Date Place Removeti
2 �Removal i and/or Held
and/or ' Address
1 Hold
cn
0 ' Date Point of
Transportation Shipment
5 by Common I Destination
Carrier i
Date Cemetery Address
Disinterment
' : Reinterment 1 Date I Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ..\1:'NL _;1 LZ. 1 HO ill�. C t t '1 C
Address
1\ Le,cay e_ - - mac_,-5 �, 1 I iffy IZ C`l
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
CC
UI
Permission is hereby granted to dispose of the human Arm de&cn. ;b• - - indi ed.
Date Issued q.- ,-,ol(., Registrar of Vital Statistics b
(signature)
i-:-• Dtit.014,,,,Li
District Number Place �p l�V\
I certify that the remains of the decedent identified above re disposed of in accord with this permit on:
111 Date of Disposition 11(7iI. Place of Disposition ZOtmd' � /u*—
(address)
ia
I (section) (lot number) (grave number)
Name of Sexton or Person in Charge f Premises diti0-., S,.""4,0-
Z / tease print) p
3 !✓L �c2 Title Ce f i "
:, Signature
(over)
-
DOH-1555 (02/2004)