Linendoll Jr, George rust
NEW YORK STATE DEPARTMENT OF HEA;;_TH 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
6&or9e., 1 i.ve.ou ci d (i tr /41
Date of Death Age If Veteran of U.S. Armed Forges,
!p 0.9- 4f3 93 War or Dates Vier ;MM I 1 -6f
j4. Place of Death / Hospital, Institution or ,/
Z City, Town or Village SGf7 i-re Street Address a y'0Y Mc ,111 faP,
0. Manner of Death Undetermined Pending
o-Natural Cause Accident ❑Homicide �Suicide
its Circumstances Investigation
ill Medical Certifi r Name Title
04 Cy Z 5 a 14) e-r-19 A id m y
Address
Death Certificate Filed / District Number , Register Number
City, Town or Village 3 CIF )-tin i J(o -5
>'» ❑Burial Date Cemetery or Crematory
1 s•- A S- i3 Chu*vim C~►4 TCY
❑Entombment Address
,.Cremation qiu_e_10.„.1.0v,y i11.Date Place Removed
2 ❑Removal and/or Held
C and/or Address
H Hold
i3
Q Date Point of
en ❑Transportation Shipment
G3 by Common Destination
Carrier
n Disinterment Date Cemetery Address
ID Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home :A✓✓ -A _ -iX Ft)kw-la I i4'_- .-19
Address
SC-4 Merl_ t__
Name of Funeral Firm Making Disposition or to Whorrf
# Remains are Shipped, If Other than Above
Address
X
111
a" Permission is hereby granted to dispose of the hump ra ains described above as indicated.
Date Issued C�'- a�- 13 Registrar of Vital Statistics GL 4.�i'�sZ c 1 c)Ct A�
(signature)
District Number Ls63 Place _e____h
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
to Date of Disposition 101306 Place of Disposition Rnii.041) 6wmctot-jur--
2 (address)
I
co
c (section) I number) (grave number)
0
0 Name of Sexton or Person i Charge of Pr mises r ri ✓ 5i stet}
(pleaset)
ICJ • C
Title (1Ximi
:i Signature77'12.
(over)
DOH-1555 (02/2004)