Koskinen, Gunnar IT
NEW YORK STATE DEPARTMENT OF HEALTH �'2.-
Vital Records Section .i , Burial - Transit Permit
Name First Midc�� I a ,ov s%/ Sex
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0 Date of Death Age p,C,_ If Veteran of U.S. Armed For es,
j �� die:R p c,t War or Dates Forges,
8, Place of Dea Hospital, Institution or
City, Town or Village �j CAI. /- L4�' Street Address �-A.6. BEES oS'P/??- L.
ti Manner of Death[Natural Cause 0 Accident 11 Homicide 0 Suicide �Undetermined Pending
Circumstances Investigation
fu Medical Certifier Name Title
c.j'E/9•il A 7ghfv n. D4
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, Address
= /t90 /?Q 4".S 69 Cif)-� '�tiA/V /c2dD
:> Death Certificate Filed / District Number (/ Register Number
City, Town or Village 6 � BLS �� 'f'l 3
;: <OBurial Date<_ ❑Entombment //`���`'� Cemetery or Crematory
T 40,e.l//E fJ C� TMo}f 6 tart
<:, Address ��
'�<_> Cremation to!La--
;>' Date Place Removed
Removal and/or Held
and/or Address
Hold
CI Date Point of
0 Transportation Shipment
by Common Destination
Carrier
: 'El Disinterment Date Cemetery Address
''' Reinterment Date Cemetery Address
M. Permit Issued to / Registration Number
>' Name of Funeral Home LC �J•er ,-2S"
Address
3 6 se4 oe( LS t-,4 c.s M / /a /
Name of Funeral Firm Making Disposition or to Whom
... Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
i:iir Date Issued 1 /3 0// ? Registrar of Vital Statistics (Ai
(signature)
District Number c 6 c7 t Place 6 i_s \` S Iv Li)
"'� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition i /31 At Place of Disposition -e....etkuj Cren►Qt nrw�-
(address)
in
Ke (section) (lot number (grave number)
0 Name of Sexton or Pers in Charge Premises ih t,ii r e�,��
Z please print)
Sfa ignature /_�/ _) C2
9 Title EM A -
(over)
DOH-1555 (02/2004)