Kraus, John If
NEW YORK STATE DEPARTMENT OF HEALTH ,'" v `L
Vital Records Section Burial - Transit Permit
Name First Miid�\dle Last Sex
SCAX VN - \/\ARAWi \il\N
Date of Death Age If Veteran of U.S. Armed Forces,
Q 1 \' 10 War or Dates
IN PIS e of Death Hospital, Institution or . —��j z.,
City, own or Village 1 "�S , ,`'j Street Address }P s\ R. S VK` \ %kk;
er of Death Natural Cause ❑Accident ElHomicide ElSuicide ❑Undetermined Pending
ILI Circumstances Investigation
W Medical Certifier Name Title 1,
Address
Death Certificate Filed C,, v� i Tq�,g� District Number 1egister Number
City, Town or Village �i `(p,z.v__ 4,r,
❑Burial Date Cemetery or Crematory
\ \'/fll
❑Entombment Address
Cremation
Date Place Removed
2❑Removal and/or Held
and/or Address
�= Hold
t
O Date Point of
u.
❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to �. Re�gisOtrat�tor�Number
Name of Funeral Home d N \ CE- \`\)(V��;UR1.-- QAQ E 44--
Address 4Q244 `!. . 1 lSJC ` ).i ,C t � \ ko
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
• Address
lIl
a` Permission is hereby granted to dispose of the human remain crib d abo a as indicated.
Date Issued \\'O �d\'..Registrar of Vital Statistics
(signature)
District Number 4501 Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f.
Z it
i f Date of Disposition I /h I it Place of Disposition em V �� C.+..c{dr;�.,
(address)
ua
c (section) l� - (lot number- (grave number)
• Name of Sexton or P rson in Charg of Premises [/ r:>� Lr ....)e,utik
(please print)
iii
Signature 0/4— Title Ciz 0f100-
(over)
DOH-1555 (02/2004)