Schreier, Francis _ 1t13
NEW YORK STATE DEPARTMENT OF HEALTH - ''
Vital Records Section Burial - Transit Permit
< ' Name First Middle Last Sex
First,_
C i S J A� , c lAVZ-E ) G-cL tvl
'ai Date of Death ( Age If Veteran of U.S.Armed Forces,
_- 03. j t)4 ! d) s 0. War or Dates
Place of Death Hospital, Institution or
City,Town or Village b L1:,rN S -FA Street Address Li_ t•-)S A i--5 Ho ST 1TA`-
Manner of Death®,Natural Cause Accident Homicide Suicide Undetermined �Pending
Circumstances Investigation
us Medical Certifier Name Title
V1) — )-% 6::\J \JAZu(3 � E V1 i)
Address
liii Death Certificate Filed District Number Register Number 6)3
City,Town or Village &LE 1- S VA S.k.-S S 100 1
IBurial Date}a. 1 S /,,v , Cemetery or Crematory
Entombment Address p,
®Cremation Q v.)14 tt..t- Z- 7 0 v C.,Ci Na b e cc'1 N`I ag 64 iiiDate Place Removed
Removal and/or Held
and/or Address
ug Hold
fil
0 Date Point of
10 Transportation Shipment
by Common Destination
Li
Carrier
:` ❑Disinterment Date Cemetery Address
-- Reinterment Date Cemetery Address
-> Permit Issued to � 11 Registration Number
Name of Funeral Home Maynard -D !�. run
era-erc�1 T-1 c,rr Q I I
Address
11- LaTCLye+4e. Streef , Queensbu.ry I New `/ow lc 1a $Oy
...
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
AU
Permission is hereby granted to dispose of the human ains d scribed bovve aas ndicat .
Date Issued o f; Registrar of Vital Statistics C ��-1 .�'/< ?/`-t'
>r a (signature)
'_ District Number zee/ Place A /
<< I certify that the remains of the decedent identified above were disposed of in accord with this permit on:
k
AU Date of Disposition Z,(11)9 Place of Disposition gewiLi 6440r—
(address)
IU
iZt
(section) ji (lot number) (grave number)
aName of Sexton or Person in Char of Premises Af, .Sn
J, (please�I
Signature �G Title '41171f
(over)
DOH-1555 (02/2004) '