Klein, Robert NEW YORK STATE DEPARTMENT OF HEALTH S 4 ift
Vital Records Section Burial - Transit Permit
[,!.k Name First MiddleLast i Sen)
Iabe(i- -pa.�1 K le( 11
E. Date of Death Age by
If Veteran of U.S. Armed Forces,
az i a ud 'otO( S" War or Dates NJ v
Place of Death Hospital, Institution or
City, Town or Village Qtit 6V(1-( Street Address 65 Kie•eJl-e gric Cord-p 714 q
Manner of Death❑Natural Cause C Accident D Homicide XSuicide 0 Undetermined ri Pending
Au
Circumstances Investigation
iiii Medical Certifier Nary,e .. Title
Jim HtAIQh4i Colon-e
Death Certificate Filed ict Number IRegi�ter Number
City, Town or Village ,e-e.i(/2o t (.$) (��
----tt Date / ( CemeNry,or Crematory A
_l Burial 0(11,971 Crj re 11-r V I•Lc c) l..r-em_Ccsla,rt.�
Address 1
Cremation akcje-e Q...t.SLD-r1 S bcfs.4 ki S,
Date i Place Removed
g El3❑Removal and/or Held
.- and/or Address
E: Hold
O Date Point of
Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::::: 0i Permit Issued to _ _ j/ Registration Number
Mil Name of Funeral Home �3 z�z. _L__ ��%"�2.3_ /7 Nt 01/ 39
;U: Address cm
11 t i -� "-r-rv'" • , 0 v6a.:.,s 6 ci r /2.
Name of Funeral Fj(m Making Disposition or to Whom r -
Remains are Shipped. If Other than Above
Address
i Permission is here y granted to dispose of the human emains desc 'bed a v as indicated.
<I Date Issuecid 49 fc Registrar of Vital Statistics LA ,
: :1 (sign ure)
im
giP
District Number`s-n Place t �l s1 Ct.) t-A
I certify that the remains of the decedent identified above were disposed of in accor ith this permit on:
f-
W Date of Disposition -)-0- I� Place of Disposition 'Rine v•'e u1 C.rt,i. ucto rn'vwr
2 (address)
iii
i (section) (lot number) (grave number)
O Name of Sexton or Person in Ch rye of Premises` a4i,yy • Zrvhelk
g J-� (please prird)
W Signature (' Title Crr_sa d ur'y t4.s •
- (over)
DOH-1555 (9/98)