Steininger, William NEW YORK STATE DEPARTMENT OF HEALTH I - N_ n CC
Vital Records Section Burial - Transit Permit
Name First ` Middle Las i ^ Sex
Date of Death Age ( If Veteran of U.S. Armed Forces, tl
1C-)
J 2D j ZOl"1_ (.t Ln War or Dates IU I F-
. Place of Death Hospital,Institution or
`.wP City, (ow r Village V3 Qr(enS u Street Address 1 W L.b rar./ A-Yen&
<; Manner of DeathK Undetermined Pending
Natural Cause �]A ident �]Homicide Suicide [] g
s Circumstances Investigation
. Medical Certifier Name Title
x ��n,1 CVrinnrI n In
- Address
a1t_--7 n S wo rr-en3 d,,r9 I 0 12��5
Death Certificate Filed District Number Register Number
City,Town or Village 610(00 X-
t�<�''ty Date \ Cemetery or Crematory
Burial ®\ I Z.-1 I -2-0k h P \i C.v.) C,C trA Gt}O{1
Address
Cremation Q\ YVS\OU I ./\ 1 Z Sg
Date Pllaice Removed
g❑Removal I and/or Held
••�. and/or Address
1 Hold
0 Date Point of
St Q Transportation Shipment
a by Common Destination
:::::1 Carrier
[-,Disinterment Date Cemetery Address
::::: ElRenterment Date Cemetery Address
:. , Permit Issued to ne�czl m� Registration Number
y Name of Funeral Home c/�11( 2rCJ 15' keT �u Ql 130
Address ii La-rat-ROC • , bu�¢.e.fnbund i/Ue w LJUrIt- /OR)/
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
'12
Permission is h y ranted to dispose of the human r described ve as indicated.
Date Issued Registrar of Vital Stabs ' J i _ , K62= -'-----
()...)(,?,17-LiAS
�ig/nature)
District Number 51 Place L� v / V
:`: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
rik f 113/f 1 Place of Disposition '[�r€ U M"s to rs+�`r1
Date of Disposition
(address)
Ui
CA
> (section) //�/l (lot num (grave number)
WI Name of Sexton or Person i Charge o Premises G 1' ( nnlit
Z (please print) '
Signature Title aCill
(over)
DOH-1555 (9/98)