Heinemann, Deanice NEW YORK STATE DEPARTMENT OF HEALTH 41 LIN
Vital Records Section i Burial - Transit Permit
Name ilst Middle Last i i Sex
Date o e th Age If Veteran of U.S. Armed Forces,
i /�0/3 War or Dates
Place of Death Hospital, Institution e.,,
I- City, Town or Village /��fi ll� Street Address -�f- C/ , /
Manner of Death 'Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
iLi L.) Circumstances Investigation
W Medical Certifier Name Title
Address o� ` Al ',__Cf7 ‘/C/ii/-;j /[ /�k�,
Death Certificate File l //D District Number / Register rpt�er
City, Town or Village �e4jf/4-14 ,5-- rT/ !/
❑Burial Date Cemete�/or Crem�jtp®ry ,4/'�
['Entombment ���� / ,) 3
/ ' r (//Yw 1r&?Y/4,7/
Address e
remation aktee.,S lJ
Date Ga Place Re /
4:2 ❑Removal and/or Held
and/or Address F;
to
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date _ Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to &7?/-0%fr—h2C,a-ee.446
�/ Registration mbjar
Name of Funeral Home �/ wvai/A erip/y/
Address gl?t° Oesieckimi9 S 7= /) 7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Cr
tu -
�' Permission is her by grated to dispose of the human remains de cribe
ab e as Zed.
ated.
Date Issued 7P3/ /3Registrar of Vital Statistics -Z2��tf .in
(signature)
District Number 6d, Place 6/''is /JCL 4 s, y 4
`"` I certify that the remains of the decedent identified above were disposed_ of,in accordance with this permit on:
Date of Disposition '7"ZS=I Place of Disposition gcsAVtev) ile'ft-itOtt''*--
(address)
in
CO
(section) X)f, %. (I t number) (` (grave number)
J
a Name of Sexton or Person ' Charge of P emises >t LNK
2 lease print)
it Signature ci Title Car Minot (over)
DOH-1555 (02/2004)