Reichenbach, David t t'
NEW YORK STATE DEPARTMENT OF HEALTH - - # 361
Vital Records Section \ Burial - Transit Permit
!Vi Name First Middle Last I Sex
VA DO4N id Re,on eiN'o 0.6r\ ! t-N
Date of Death 1- Age if Veteran of U.S. Armed Forces,
MA ot I 12.1 0.01)tti. ' /lb War or Dates Ick5t,D-t ct 51
Place of Death 7 Hospital, Institution or
City, IM•r Village Qv.eevs,..VOLi.r4 i Street Address 3ira,m.c.•n AI%Ars;irz5
is- Manner of Death E.Natural Cause Ei Accident El Homicide D Suicide n Undetermined El Pending
AA Circumstances Investigation
z Medical Certifier Name Title
C1 gos\In Socoloce
Address
152- SY`e""" i1/44entAe• GVtcuS "-"A‘Ns I Nli/ t2- (DI
... ___
Death rtificate Filed ' District Number I Register Number
Ng City,Lrowor Village Qv•-eenSbukri i 5GS.1 i (Ay b
... f.....1 Date 1 Cemetery or Crematory
Li Burial 05 1 13 I 2.0 t.--N
i 'iNeve- V ie-o•-) Cf%e.Cr%et*-Ct r 7
Address ---1
:: MCremation 0,0„f4D6Notkisf
Date . lace Removed
Z 1-1 Removal . and/or Held
tt and/or Address
r= Hold
V)
0 Date ; Point cif
poi E Transportation : Shipment
a by Common Destination
:...: Carrier
Date , Cemetery Address
• Disinterment
::-
Date Cemetery Address
Reinterment
M] Permit Issued to 1 Registration Number
Funeral
W Name of Home Ct-yr)(2 r 6. 80..i F,.
ter- .4..ner-rd Home_
CI
A Address
I I tara 1-1 cttc cY. , ( ut-k-cr)sicx-tr cj , Ale_w Lkrit I.2 AY]
Name of Funeral Firm Making Disposition or to Whom
____.1:•."' ARemains are Shipped, If Other than Above
a _1
OW ddress
4---
Permission is hereby granted to dispose of the human remis dELscrrib- • - • • , as indicated.
Date Issued --1.S-pplt1 Registrar of. ital Statistics ( DLCAJ)
(sigha )
M
District NumbCrLS 6 -7 Place LA
-.., I certify that the remains of the decedent identified above Lre disposed of in accordan•- this permit on:
.1.,-
5 Date of Disposition 5-ii-Iti Place of Disposition
2 (address)
W.
(/)
CC (section) g (lot number' (grave number)
° Name of Sexton or Persons Charge of Premises Aittitt-
CI
a
Z • (please print)
41 Signature It 1-- Title Ctivleirt,
i
(over)
DOH-1555 (9/98)