Herbold, Harry / S (-'
NEW YORK STATE DEPARTMENT OF HEA'_TH
Vital Records Section ' Burial - Transit Permit
Name First, Mid le Last Sex
/ry%r9_____gA er 1cA
Date of Death Age If Veteran of U.S. Armed Forces,
(575- War or Dates — 99'(
I- Place o 0--ath Hospital, Institution or
Ci ow •r Village (�eeh�' Street Address
3 Manner of Death -Natural Cause Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
W Circumstances Investigation
W- Medical Certifier Name Tit e
GI 4.<54/1
0C-OW fifLP _
►� L��.._._✓1 C ti.ee, '`�, V _ a _
Death C cate Filed di t Number _J Re er tuber
Ci , ow r Village�t eeit �9�
Date Cemetery or Cremptory
❑Burial d3 -.2/-i3 l' e- Vie,‘,.) . ✓$'L"'
❑Entombment; Address
►_�Cremation i 1 ,11 c .7,-- A90 &enoved fftl
Date
Z Removal and/or Held
2❑and/or Address
F- Hold
U1-
4 Date Point of
5 0 Transportation Shipment
fa by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment i Date Cemetery Address ^—
Permit Issued to ( 1 Registration Number
Name of Funeral Home la\fo :Ll e4 D- upG.Ki 4 F Lt.1*-((i } f C't.)ti 1 C° I i Cw, -
Address rL.Ci,"1Cl \/E1 -I C -1C cc A ` i j((et. ( isf_)l l ( y , \a 'ti.•` 10r. �t i ()i (v•)1 1
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
IC
iLk _
. Permission is hereby granted to dispose of the human r mains described above as indicated.
Date Issued�1 � l�Registrar of Vital Statistics CIS
lL.t \
(signature)
District Number a S') Place 1 cf) C)_- C3(- n ,....„1_,
I certify that the remains of the decedent identified above were disposed of in accord;nce wit this permit on:
tail Date of Disposition c9/-/-3 Place of Disposition )vcf Vi.' si 2)f
2 (address)
W
CO
I (section) (lo number) (grave number)
aName of Sexton ,Per on ' harge of Premises _ Sa��tf_ 'OcA11 d
Z (please pant)A
Signature, ` __-- Title (... ' r Hs1-
(over)
DOH-1555 (02/2004)