Guthinger, Jeffrey NEW YORK STATE DEPARTMENT OF HEALTH ` '5-1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
O3 foot (dots cCk War or Dates --
j- Place of Death ( Hospital, Institution or
City, Town or Village VLEt- S VAS-%-S Street Address (Lct SC-At_.5.— k4oSP11 A (—
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0 Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
La Medical Certifier Name Title
TO A t-) Q, SI-0 Q T C is R,V PI\')
Address -
t b 1 PAR. 5 C>LE.,�S C A L-L..s ►J`N, (')—$C1
Death Certificate Filed District Number Regis#er umber
City, Town or Village (oc..G. I.-) s rA��% „. to O 1 1 l
El Burial Date r etery or Crematory
01/ C> / 0,O t S �. \1 t E\.J (, N►AT ott.ti
Mi['Entombment Address
®Cremation Q..-1 IAt1-G IL R-0 QuEEt�s gv tL-t t- - r'l86 Lk
Date Place Removed
Z Removal and/or Held
❑and/or
E Address
Hold
0 Date Point of
E
to L jTransportation Shipment
25 by Common Destination
mi Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 11.\`-1 tJ I&c j V. As LE.CZ t 13 Q
Kg Address
Ai 1.\ L A. F!�- E T i€ ST O v E ►-- s s v Ct-'-• IJ'1 l a-%c)
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
W.
P` Permission is h reb granted to dispose of the huma remains des ribed above as i dicat d.
Kg Date Issued 63 c 7 _5 Registrar of Vital Statistics ,i_��, 7 ���`<_
7-) (( i na ur
District Number j Place r_1 - `lam l
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OI certify that the remains of the decedent identified above were disposed of in accord ce with this permit on:
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LU Date of Disposition 3J SJ t6— Place of Disposition MIV I 1 ��V
2 (address)
ill
1 (section) (lot number) (grave number)
ci Name of Sexton or Person in Charg of Premises Alit— ,St4, ,-
�/y1 ( se print)
Signature Title faK,s1 Aq*
(over)
DOH-1555 (02/2004)