Hoeger, Herbert NEW YORK STATE DEPARTMENT OF HEALTH` -. 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
M %4Elke) (2.1" i-koe."1.26 R. In
At: ,
iN Date of Death I Age r, I If Veteran of U.S. Armed Forces,
111 10 I 9,6 I aok,1/4k "-ID L War or Dates "---
-i.: : Place of Death
!..- City,Town or Village DA.)C-61-1s%\A--"N
:-, Manner of Death
i
NA Natural Cause 0 Accident 1 Hospital, Institution or
01 StrHeoemticAiddedreoss 5st1iici.::-.94,41....E"Erl 1,...44,E: Ae.v kgsc\
ni Undetermined ri Pending
`—'Circumstances Investigation
0— •
iti Medical Certifier Name Title
41 LIAT....‘sl-C>1/43 V1E V-. 1-kOLA Dr\-C)
Address
Afi
I 6 k C-A .et-k. 4?,'-‘)
le
N] Deat ertificate Filed Disyjt Number Register Number
8 Ci ,To n\pr Village V.Q.a.1 ),". CDS-P.) i,1g,
Date Cemetery or Crematory
--i t__I Burial Lb/as./go'1 i (3‘t.Ne \) 1 ew Q.QC re\Avow`A
.... E-21:i Address
04.1 Cremation OtiAiLEK iikOAD OuEE, N5 "( L ., 1,...)`-k t -1-gOkt
Date Place Removed
3 1-1 Removal
and/or Held
and/or
.4 Address
.... Hold
1 Date Tint of
g Liri Transportation 1 Shipment
a by Common Destination
:::: Carrier
--.:.,. r---1 Date 1 Cemetery Address
u Disinterment
Date Cemetery Address
Reinterment i
i
-.:.•
It• Permit Issued to ul
l 1 Registration Number
Name of Funeral Home i. Hatra rd b &Liter FLerai //acn e_
I on I 30
i.1 Address ii L_.(,_ , , , , , I , toeol
urcuic,I-Te Or. , (-4(A cznsiotlad i NUL) Yorlt /
Name of Funeral Firm Making Disposition or to Whom
r... Remains are Shipped, If Other than Above
Address
=
0,,,,,
40.t.
Permission is hereby granted to dispose of the human re ains described ab,ne as indicated.
Ili Date Issued lot ag,la019 Registrar of Vital Statistics a fu.....,-
(?igsature)
CP
M District Numb (ctS-'i'--) Place
•••••••• I certify that the remains of the decedent identified above were disposed of in a 'ordanc with this permit on:
1.!
Z IA--
Date of Disposition j41411 Place of Disposition
a (address)
IV
IA
CC (section) 1 ot number (grave number)
(--) Name of Sexton or Person in Charge of Premises
CI .47„A_ Usst-itt-
t I (please print)
..!.!! Signature Title MP-tili-N-
(over)
DOH-1555 (9/98)