Heyer, Bruce 1.111r 4e'
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NEW YORK STATE DEPARTMENT OF HEALTH ,
Burial - ransit er i t
Vital Records Section ..
.:t. Name First Middle Last Sex
1.42:vutteti._ a , likie,t,
..
AgeDate of Death eteran of .S.Armed Forces,
3-3o--/; 79 War or Dates
z Place of Death
5+„City,Town or Village 5
Hospital, Institution or
w 1-‘,A1 CretV, Street Address 5- 1 efiry,LrOdif l , Ci-rOk. OTIS?
4.:tf Manner of Death 11.1 Natural Ca6se 0 Accident El Homicide 0 Suicide ElUndetermined 1:1 Pending
Circumstances Investigation
Medical CertifiA_ Name Title
auLLL 61 t_L.Aril MO
quAddr
Death
District Number Register Number
City,Lown r Village /IV 56 --F
Date etery o(iCremato
El Burial
vAddress Cremation
01 Z Date Pla Removed
O 0 Removal and/or Held
I- Address
cn
a_ bate Point of
tn 0 Transportation by
...._ Shipment
in
Destination
Date Cemetery Address
Ei Disinterment
Date Cemetery Address
0 Reinterment
,?--' Permit Issued to Registration Number
..-. Name of Funeral Firm /WA_ ).e,.1ress
,,... Name of Funeral Firm Making Disposition r to Whom CJ
Remains are Shipped, If Other than Above
'CC Address
LLI
.. . /1
Permission is hereby granted to dispose of the humar)remains s ribed ab ye as indicated.
Date Issued 4it), Registrar of Vital Statistic k V..../../Aelethc, _____________________
(signature
fi n,.--•
.:-:: District Number,`)658 PlaceL..../0-2mi ay \..;, j idjAi
. .,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I--
Z Date of Disposition A r i 3(101- Place of Disposition f;(4/Vkai Ctufty{of K.,
uj
2 (address)
LIJ
U)
CC (section) (lot number) ...... (grave number)
0 4
a Name of Sexton or Person i Charge of Pr ises rolll../.. •• et.t.t1A—
Z (please print)
w
Signature WL_ Title COQ bilk-704-v
DOH-1555 (10/89) p. 1 of 2 VS-61