Rogge, Bernard NEW YORK STATE DEPARTMENT OF HEALtH' IL # Z
Vital Rem Section Burial - Transit Permit
ry Name First Middle Last 0 Sex.
-- �� q o ' ri
Date of Death Age If Veteran of U.S.Armed Forces, �J
v5 j al 1 a cat y ? 3 War or Dates 16161 1°15 3
; Place of Death Hospital, Institution or
.. City,Cr' r Village eer o tr Street Address Lan�eCtrV i eu� �. �.
; Manner Of Death ; 1 Natural Cause ❑At D Homicide ❑Suicide 0 Undetermined ❑Pending
s Circumstances Investigation
. Medical Certifier Name Title
Eric pivvexner- ILA
.. Address
100 'Pay` Skieelc- l C x tea.A\S, Q,-1 1 31
` Deathyy, CertificateorVIaite �o� � �0� a\ i Number Re Number
Date )oi_j
Cemetery or Crematory
Q OEM aC -( Fi0t v+ eck, er-ernet)-67
Address
(►'l Cremation to nrkx,a,r
Date I ' P Removed
0 Removal is l
};.; and°r Address
F Hold
0 Date rant of
Transportation Shipment
4 by Common Destination
Carrier
: :❑Disinterment Date Cemetery Address
[]Renterment Date Cemetery Address
-: Permit Issued to
Harald Q exi i r Fw el� 1* ne Registration O/ Ntttrtber
Name of Funeral_Honme ! r
Address /j LG�
Q.i fYe cam. ,( Ufa/Is - r JU- et,3 Or
iagC�y:. Name of Funeral Firm Making Disposition or to Whom
: Remains are Shipped, If Other than Above
Address
•
r4'' Permission is hereby granted to dispose of the hu remains described above as indicated.
Date Issueds I c^}0 cy Registrar of Vital Stab,' q, _P ..„,:„
signature)
0
District NumbecJ _Dc 1 Place -Y-• 0 -,•
I certify that the remains of the decedent identified above were disposed of in. dance " this permit on:
F
L Date of Disposition VS'l ig Place of Disposition 644. ( i_4r-
* (address)
Ae
(section) (lot rum ) (grave number)
0 Name of Sexton or Person Charge of Premises A
f1 (.. )
g (please print)
Signature 4 L_ A Title 1446114.10/
• (over)
DOH-1555(9/98)