Eckert, Gene 3 NEW YORK STATE DEPARTMENT OF HEALTH r - ' tr
s1C
Vital Records Section Burial - Transit Permit
iiii Name First __Middle Last ,,/� Sex
Mi �o4.'t1e— 1K El5✓e-f/ Lrc-Ker7— Pi
0113 Date of Death Age If Veteran of U.S. Armed Forces,
>'3 0 7 — (6 - )-0 I y I .,_ War or Dates / y or/o2,
mi
tGc -
t' Place of Death Hospital, Institution or //
City, Town or Village M/meira A 1 Street Address q'/ 0010 Ae`it -
Manner of Death 0-Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name ) Title
-40
e- "Fr -i.S VAri A Th
Ad ress
- o ON SIGa i,PA/e- G'/ACid tea: / a9(7/X
€: Death Certificate Filed � District Number Register Number
€' City, Town or Village 1,/' 11�Pee/A l.S _S—
Date Cemete or Crematory
❑Burial 0 q -/,5. - d El i Ne 0/z/A) e he-en N /e 1%-y
Address
:5: Cremation G li ia-e -15 1 t?y y qJ>/',
Date Place Removed
fl❑Removal and/or Held
•r and/or Address
0 Hold
0 Date Point of
y ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
- <'. Permit Issued to / Registration Number
ik giiName of Funeral Home EW 13 � . e.: / 1v Ne via / H c' - Op S l q
iig Addres..._ c--4 kl)--0N-- A l'. et.- i,\....). / F7O
4 Name of Funeral Firm Making Disposition or to Whot
Remains are Shipped, If Other than Above
IAddress
i
»' Permission is hereby granted to dispose of the human ains described above as indicated.
Date Issuecl'1 1-Q--\ Registrar of Vital Statistics c�"" i _c .:a_..4'��J
(signature)
>' District Number 1,“-7. Place tiV//Jp!<''(Ji1 N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
>EiJ L✓ e
� Date of Disposition ��t'1�1� Place of Disposition ,�i ,
a (address)
U)
CC (section)
Name of Sexton or Person in Charge of Premises I, t number) {grave number)
rr1- if..N 9-
g / (please print)
. Signature GL Title Crif-affrpol
(over)
DOH-1555 (9/98)