Tausinger, William NEW YORK STATE DEPARTMENT OF HEALTH, 511.1
Vital Records Section 7 Buri'A - Transit Permit
rif Name First i j \ Middle Last Sex
Y v rn �0.)..J,. ;i Qom' 1
>< Date of Death `2..0 Age , If Veteran of U.S. Armed Force
1 (9Z ; War or Dates
LI pia a of Death Hos ital Institution or Z
Ci s i lage Po treet Addr / I L� 0
, Ma ner of Dea%a Natural Cause 0 Acci nt Homicide 0 Suicide 7 Undetermined �Pending
La Circumstances Investigation
fil Medical Certifier Name — Title
Ci I--r .r cA t�h its-ls.1 t_) l CO -r'
5' Address 60 M a pLQ. lane, 61carnl, da,lk, i-- Zq 13
:; Dea Cert' ic- -_ -d A ' d `�! District Number Register Number
Ci rifir't. Villag- H Crcc ,s . I 1s 22— ;
Da e `1 2O m Cemetery •r Crematory ry p Irv- vs
1 e_3
❑Burial
Address
:.:: cremation U 1 `Zd ,1 0 r�IQQ.s Jt. 3, l�` 12`zOL
Date Place Removed
Z�Removal . and/or Heid
and/or -- ---
},; Address
Hold
0 , Date ^-- ,—,-- of
NQ Transportation i j Shipment
a by Common Destination
Carrier
�j Disinterment Date Cemetery Address
`::, I I Reinterment Date Cemetery Address
- 1 Permit Issued to i Registration Number
Name of Funeral Home 'Baker Fu.nercz/ I dome 011 o
IN Address // LC><Q y_- e 3f. , b l,t c.nSia,t-rcd ; JUew L/U/1L l a eo
1 Name of Funeral Firm Making Disposition or to Whom
M" Remains are Shipped, If Other than Above
Address
iu
Permission is hereby granted to dispose of the human remai s described abo indicated. 4D
uate Issued —
F3 5 Registrar ofVitai Statistics — . • - j//La
(signature
1District Number /5-, g Place �( Ma)n , .J, poil ,,,,r Ai ` 129 '1/
7/ 7r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1 p
5 Date of Disposition g l l I(c Place of Disposition i,K 0,...+ Cr �r,,,,,
W (address)
in
Cr (section) t number) (grave number)
AName of Sexton or Person in Charge of Premises ,�,s. �c,,�y,Af
Z Q (please print)
i1. Signature /�-�" Title ti7F,.►+'t}> ,'.
(over)
DOH-1555 (9/98)