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Linck, George
NEW YORK STATE DEPARTMENT OF HEALTH 1/ 2 l " Vital Records Section - Burial - Transit Permit 'J Name First Middle Last Sex. . ,< Ge)r L',nclt.. N\ : Date of Death �� Age If Veteran of U.S. Armed Forces, 1 q•}Z- t ay5 CS\CS,1 Zp' Cl5 War or Dates 3. Place of Death Hospital, Institution or . City r Village GokeenS\Our_j_ Street Address a-AY\. -o r` v.rS. nq �o+� Manner of Death[atural Cause 11 Accident Homicide 0 Suicide Undetermined Pending 5 Circumstances Investigation 4 Medical Certifier Name Title Suzann? V\oork KD Address '<1 \5Z er+nctn \\ \ O\ ��th�� , C�l��s S , rJ s Death Certificate Filed District Number Register Number umber �� City, ow VillageQum� ��O")' 55 Date Cemetery or Crematory -J D Burial 05 ' ©IQ )-o I`I -P',n ve ,CO Cremo- 0 1 Address � LI Cremation c )..e€ns'oury, .1 :. Date U Place Removed gRemoval and/or Held ; and/orii! Address as Hold Date Point of Q Transportation _ Shipment a by Common Destination Carrier Q Disinterment Date Cemetery Address bRenterment Date Cemetery Address { Registration Number PermitameIssued to i 'ainard v er F neral /*me. ` xr Name of Funeral Home f'� � Or)30 Address ,q Lafayette of. , b(,tiLQfiSbU.j ,1AJ tJOrk- I g 'OL Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above - . Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ° ";3111' 5 b'(1'1 Registrar of Vital Statistics `I i- fix` XcA " (signature) `,,- District Number lQ S-7 Place 0�) �e ,'\ Shvrll I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: g Date of Disposition 5- -)4 Place of Disposition acl ✓ ��+ '. (address) CC (section) tt number) S' (grave number) '. Name of Sexton or Person in Charge of Premises ��t>�'"' t►f I( L1 / (please print) g 7 +�1F L # Signature f ' Title (over) DOH-1555 (9/98)