Bgumann, Joseph # e
NEW YORK STATE DEPARTMENT OF HEALTH 5--7
Vital Records Section c 4 Burial - Transit Permit
Name First Middle Last Sex
--16 ,/ „-/1/4111' Se."67(2/.-- .-2 -'2 -,77 , ',•'',
Date of Deat Age If Veteran of U.S. Armed Forces,
�i' /'//� �i� War or Dates
P '6f eatt Hospital, Institution
� i own or Village i j?-.7-7,57-4"10- Street Address �r .i?.�_,�f -���� i%G /
-
III
W Manner of Death-atural Cause 0 Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Nam - / , Title
Address i
:iS _//,--C7 A6,4--
. --77 ed,7,..,--/--- , ,c- _,--z,-;7,42. ---- ,,-
th Certificate Filed /' �.-> District Number Register Number
•IiTown or Village((%L .5^�t`/,U ,J--%'/7 �v'�
['Burial Date 7///',5__/.4,,,
or Crematory (/
/7: 1-1. /7�i'�07 / dTJ�.�=-7[ Entombment
Address /
r< remation cf ee' _ric c' _ 7.,,� � PC`/
Date Place Removed
❑Removal and/or Held
and/or Address F
Hold
0 Date Point of
Transportation Shipment
t by Common Destination
in Carrier
(` i Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to /�/� ,r / Registration Number
Name of Funeral Home 6(J7-77 ,. ' 7;960,`,/�,c• U /��
Add es / /.
//"Z ? s/ r
.Tez
,,,, ...,,/ /2_0-7
N me of Funeral Firm
.„,„:!„,„, Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
III
mii. Permission is hereby ranted to dispose of the human mains cribed ove as in• . •.
Date Issued 0 /__ 0162 Registrar of Vital Statistics diLe
signs ure)
ni District Number_i-7 Z G-l Place Fa
I certify that the remains of the decedent identified above were disposed of in accordance with is permit on:
ILI Date of Disposition 91kf jty Place of Disposition Z.�,w --
2 (address)
ILI
CA
le (section) (lot number) c (grave number)
0
II Name of Sexton or Person in Charge o Premises r„, - nvtt-
/� (else print)
gi ilm Signature G&17. Title CIL �A Dj2
(over)
DOH-1555 (02/2004)