Hollenbeck, David 41- !0
NEW YORK STATE DEPARTMENT OF HEALTH IA Burial - Transit Permit
Vital Records Section
/4
Name First Middle , 1 Last i Sex
Date of Death Age ,.t��- If Veteran of U.S. Armed Forces,
) / 3 /a 0,3 (9 I War or Dates
),..., Place of Dea __ Hospital. Institution or /
Z City. Town ilia __ �� ^ Street Address 3/7 �c%4-7 X.
2 Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
Address
1 Death Certificate Filed ' District Number Register Number
iCity. Town or Village �D r. rt'- LT 5 kI
Date / Ceme y or Crematory 1
Burial (/ 4taaf) iVtc V.c ,_, &cM-t ,.
Address
I 'All Cremation ,A,e.—c�S ,.,ter Aje,,, /,re/C
Date 0 Place Removed
O '— Removal and/or Held
H and/or Address
Hold
0 Date Point of
Nt !Transportation Shipment
Q by Common Destination
Carrier
7 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 7).r.'`I't
Registration Number
Name of Funeral Home �,,,,rc T u.+cr.,.k. ry / ��- 0o40
Address —7
l glef,..., Ave ,,. � --rI ag).Z..,
Name of Funeral Firm Making Disposition or to Whom
1::: Remains are Shipped. If Other than Above
2 Address
14
Am
Permission is hereby granted to dispose of the human r ains scribed abov s ' icated.
Date Issued I /Y/13 Registrar of Vital Statistics
• a re) A t
District Number li 5 �t Place r. ) N�`^J 'rA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I'-- � / � /
Z Date of Disposition/�i3 Place of Disposition Avi Y - 4ii€/ 4
M (address)
ill 0
CC (section ,1 �of n tuber (grave number
QName of Sexton or erson 'n Ch r f Premises �lT dr'JDi t i
z (please print)
W i1,d�rn' - %! -s Signature ,in
Title 1.
DOH-1555 (10/89) p. 1 of 2 vs-el