Kline, Richard NEW YORK STATE DEPARTMENT OF HEALTH / /1
Vital Records Section Burial - Transit Permit
i z::::. �Name First \ Middle ,Last Sex
34.< 1
Mtn Date of Death AgeQ-t If Veteran of U.S. Armed Forces,
t4 a / /3 )/&1 10< War or Dates 1Stia- t� b
t• Place of Death Hospital, Institution or-
City.Town or Village (,l e�s ��V S Street Address -e-n S % S ��05� ��
i. : Manner of Death f Natural Cause Accident Homicide �Suicide Undetermined Pending
'mil Circumstances Investigation
Medical Certifier Name ` Title
Address ,
c h` rc0 �i``4\Vc `-,
..$.
�q C -1
` " Death Certificate Filed District Number - ' Register Number
i City,Town or Village ,LENS c A Lis I 0 ` J 1
Date Cemetery or Crematory
D Burial._ t o 1 is j a 6 f / r I )\-2 V e w Cat .
Address
Cremation ( s' QcQ Ctve,e ,,S p\. tsg0ut
Date Place Removed
Z❑Removal and/or Held
1or Address
Hold
Date Point of
0 Transportation Shipment
4 by Common Destination
Carrier
[�Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
0 Permit Issued to Registration Number
.w
Name of Funeral Home nc sn c 1
rw
Address
Name of Funeral Firm M:! a Disposition or to Whom ,-
Remains are Shipped, If Other than Above
Address
Permission is her y granted to dispose of the human ins escribed hove as i,dicat-d.
.
w: Date Issued 1 a01 4 Registrar of Vital Statistics , l ,
et (s" lure)
' ��, r� Place
va r r�� District Number � �f
_,ez, 1
F I certify that the remains of the decedent identified above were disposed of in dance Li
this permit on:
aCi Date of Disposition 2(/b ! Place of Disposition
pos ' � �y r� U!v �(�
a (address)
fil
to
(section) ( number)�- (grave number)
g Name of Sexton or Person in charge of Premises (�. ,,u,�-
fr (please print). i ,
Signature ''" Title m
(over)
DOH-f 555 (9/98)