Straub, John NEW YORK STATE DEPARTMENT OF HEALTH #Or
Vital Records Section Burial - Transit Permit
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Name First r- - .t) Middle c--4....St 1 S
3 0 ki—.) K uss c2-4...._ ,. '772-9-11 i /7192,tf
Date of Death j Age i
1 If Veteran of U.S. Armed Forces
(p-hd--- Ls- (''2_ 1 r Dates rkil 1rd-
14 5.1-. e of Death Hospital, I stitutio
g(City "own or Village 0 Lic,Is 1—g-vt_S ree ddress L..:/_ 6r.,.)....t Fez/L—c
a Manner of Death FNatural Cause El Accident 0 Homicide E.Suicide El Undetermined pi Pending
Circumstances "'Investigation
8 Medical Certifier Name Title
O- Pleln- Bo-c_wn ) CI1
:.•-•i: Address ...---
D.,.. .,t,. h Certificate Filed ---) /
District Number Register wiper
im ity, own or Village
Date Cemetery o Cremator _,/••)
n Burial /
AB h r" r)-,.)if-- n i 6,-,----
Address 0 Cremation A Q 1.Itte.-A-/Z-a ukt-e/ A7
Date PlaceK Removed / '
Z EIRemoval 1 and/or Held
0 L--1
— and/or
—iii• Hold ! Address
O Date 1 Point of
El Transportation , Shipment
Es by Common Destination
: : Carrier
Date 1 Cemetery Address
: El Disinterment
Date Cemetery Address
E Reinterment 1
Permit Issued to I Registration Number
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Name of Funeral Home LS P tel. h.;...-4.-,-.1141-(, Miye,--- 0:1/39
W Address (Ti?i
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Name of Funeral Fjtm Making Disposition or to Whom 7 i
iRemains are Shipped. If Other than Above
Address
1 Permission is hereb granted to dispose of the human remits described aboveas indicat
Date Issued Ciszic‘ a01‘,.-- Registrar of Vital Statistics L-727
(signatur
District Number\-5-6O/ Place •.(a/2 5. j Celt; /Ly 7;vey
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
EDate of Disposition At Place of Disposition
2 gitofiS (address)
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CC (section) 4(lot number (grave number)
O Name of Sexton or Person in Charge of Premises • _...tiinget
Ci
Z (please print)
P4 Signature a "eTitle ilif-liA illitt
(over)
DOH-1555 (9/98)