Fehr, Ted NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Nami�st Middle T h r Lastnk_
Date of Death Ag If Veteran of U.S. Armed Forces,
CI -d l-CAD/5_ �p3 War or Dates N p
Place of Death Hospital, Institute n or
Cit Town or Villag ra-f c 4 p w-)C s a Street Addres 1l t(l
c anner of Death El Natural Caus�Q Accident)❑Homicide ❑SuicideUndeter fined ❑Pending
til Circumstances Investigation
iti Medical Certifier Name Title
0
Address
iiiiii
ath Certificate File Dis-rict Number Regisfter Number
Cit , Town or Village. AJZt f( .�j�rl n 5 d J0I i l_.0
❑Burial Date �, I emete r Cremat ry
❑Entombment in
`" ' -02J^8 D 1� j ne .C UO ( rp-e. .""'
Addres J
IliiIii aCremation U_QL 15 bu N,
Date I�lace Removed
2❑Removal and/or Held
and/or Address
= Hold
ifft Date Point of
i Transportation Shipment
-
by Common Destination
Carrier
Disinterment Date Cemetery Address
ill 0Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiiiiiiiii e Name of Funeral Hom u 4 I s_ 1vi6 D1 I
Address„ QkLri L •
LLLZ r7 '? 'g
Nili Name of�of Funeral Firm Making Disposition osition or to Whom
Remains are Shipped, If Other than Above
Address
CC
tf
Permission is he eby g nted to dispose of the human remai scrk ed ab ve a indicated.
—Date Issued IS Registrar of Vital Statistics ' - in
(signature)
iii District Number (_f so, Place Q. (N(.t S
ii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 ,,II
Date of Disposition q/23/15" Place of Disposition Z v ' irrm4los -"-
(address)
iii
te
ir (section) (lot number) (grave number)
0
its Name of Sexton or Person in Charge of Premises •r ssr
(please print)
ILI
Signature 6Title fa 6'410(1
(over)
DOH-1555 (02/2004)