Kohl, John NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
II Name First � Middle n ,�tP� �GLastl Sex
c)h+a- HCt h
Date of Death I Age n I Veteran of U.S. Armed Forces,
1 i I 'TiWar or Dates �'
..,.; Pl..ce of Death I os , Institution or
L, Town or Village (.e N_ f'cc.tt S I try eet Address ('I I S 7-ct.
Manner of Death atural Cause Accident Homicide Suicide Undetermined Pending
ILI �.�'� Circumstances Investigation
Medical Certifier Name Title
Sine"%-Ver. Title r, Attend iry Phsk ciao
€ AddressIR 10Q �t • Gloms Poi , A8) 1 2S0 1
>::-.� th Certificate Filed ! District Number ! Register tuber
City, own or Village „ 2-n S Palo— 56t/�' 1 �
Date Cement),or Crematory
0 Burial '4.5 f I' Yve V 1.ec,6 c CerytGc'in
Address "" � ,p , rr
:>' l7Cremation ���,t!.�ikf -OG - QU Qf\Sh0f1 Ivy %rL I Z4vt/
Z Date Place Removed
O❑Removal and/or Held
-- and/or Address
E- Hold
O Date ._._�-_-------_point of
N0 Transportation j Shipment
Es by Common Destination
Carrier
Date ' Cemetery Address
L_Disinterment
Reinterment Date Cemetery Address
:i" Permit Issued to ' Registration Number
Name of Funeral Home ZCi'ker rwiercti nomC. oil 3o
>< Address
< 11 Lc rat-le±te bi-. , CJt cc nsburcj , /Uuu I'Orit- l(2'Oy
t' Name of Funeral Firm Making Disposition or to Whom
ST Remains are Shipped, If Other than Above
la Address
<<: Permission is hereby granted to dispose of the human rerCins described ab �e ass in• cated
pi Date issued 65 Registrar of Vital Statisticst_,� /, 127 ��; "(sigoit District Numbe 6C/ Place 6r&7vcr P 7 / 1?7
I certify that the remains of the decedent identified above were d in accordance with this permit on:
5 Date of Disposition C hi is-Place of Disposition ,luV✓ �,.�,-1?,n,,r.-
'„ (address)
IV
th
lr (section) Alotnumber) (grave number)
flName of Sexton or Person in Charge of Premises nit 3e.i. t
g d (please print)
• Signature Title /Vol 4 in
(over)
DOH-1555 (9/98)