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Sahler, Laurence
NEDEPARTMENT YORK STATE OF HEALTH ` 3 D Vital Records;Se Burial - Transit Permit ,.- Na ►e rrst e., Last Irtu-rS1___ a of . I Age � if Veteran of U.S.Wined Forces. -7 — © -1- 1 57 V► orDates - Place of Death ` n Hospital.. Ins_` i. or./ ; City own a Village 4� I Street Address 0 , 0 ) ) : mariner'. 1,-: t n Natural Case 0 Accident 0 Homicide 0 Suicide Undetermined., 0 Ping Circumstances investigation ,:. a_____ Tittle rt a r ,� Death,.° \ lik,eizA-- enA._ tj Certificate Filed cerhir) ' DistrictNumber ' Register Number �, Cry,Town orVe Date . ortC/r�'8fric' Ary = Burial -7 a3� „a 1 i Y i . ,, .-c,t fi- -e+'t..2.. ,.. Addr Crernatibn ) ( 2 rz.v�,� `' Date emoved Removal > andlor Held andt ` I Address ..* Hold Date I Point of ;0 Transportation I Shipment by Common Destination Carrier :E 0 Disir terment Date' I Cemetery Address Reiriterment Cemetery Address I Permit Issued to 1 Registration Number Name of Funeral Home u Address - LE 35-1 _.,)&tco±Q__ etl., 30 \._-1")t_C)s,(.(k..iL) c 'c i t,j;0 (g A ,1 ),_-5( 14 �zv Name of Funeral Firm Making Disposi in or to Whorn 1 j Remains are Stied, If Other than Above ,,.;., Address -�-- Permission is ereby granted to dispose of the human remains described above as indicated. Date Issued 1 �a 1�. Registrar of Vital stairs ct ti... C . (signature) ,. District Number .05:3 Place )0 ► L I certify that the remains of the decedent identified also a were disposed of in accordancewith this permit on: Date of Disposition 1-i;- rL Place of Disposition • p t Cn,.�( . #tion ,nL kw1 l0rl4... (address) (s+t�vn) /j rj pot numb (' (grave number) Name of Sexton or Person in Charge of ises -,,ke r J er,,,r114 - print) rf Signature aL, rife Ctti2`t4 A7E-i) ,. 4, _....... .s__ .._..._. . .