Soldwedel, Frank 'h
NEW YORK STATE DEPARTMENT OF HEALTH \ A Z
Vital Records Section Burial Transit rmit
gi Name First Middle st Sex
r ran k- E. SCi del 1
ill Date of Death q 113 Age If Veteran of U.S. Armed Forces,
War or Dates i q 5(n-1 qs g
:! Place • �eath L
ow a . -•- Lab- Ciec (Street Address I�� S I-a�e .qlV
::. Manner of Deat. ar Cause ❑Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name ---
DON id CLnn _^h,� ,�^ Title Nb
C r ' �c.0 Y 1
Address 3 i( LC CC..n-fern /lens Fails, AN I a zo I
Death Certificate Filed District Number Register Nu ber
Tow. or Village Ia- C�e�r� �� /
❑Burial Date /ioJi3
f V
�{ Address COY(.ca,- by., oute�n bui i t i t�7 scT
Cremation
Date Place Removed
0❑Removal and/or Held __
••• and/or Address
Hold __._.__ -
Date _ T 6oint of
Q Transportation _ _ j Shipment
5 by Common Destination
Carrier _ ___
Q Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
iiii8 PermitameIssued to t1 nand n b er r�� � fityyy_ Registration Number
Name of Funeral Home Maynard l� l�
Address i i L a fay tUe S -., (�i c,¢.¢.i s bi.tili, y l a 04
"i`i` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
N
<< Permission is hereby granted to dispose of the human remains de ribed above s indicated.
<€ Date Issued 5- O-L3 Registrar of Vital Statistics 1111s sir it i.. CLI-It
(s..nature) i
iiiiiiii District Number S% Place , , °A i
I certify that the remains of the decedent identified above were di.posed of in accordance with this permit on:
F �
alDate of Disposition 5-G-i3 Place of Disposition rTr,xd L. Cn.n-cfrs‘vi-..
2 (address)
Ili
U)
CC (section) A
(lot number� (grave number)
GName of Sexton or Perso in Charge of Premises i l 3ei I f
F (please print) I
U: Signature l.._ L Title C1? t41070.
(over)
DOH-1555 (9/98)