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Meissner, Waltruat NEW YORK STATE DEPARTMENT OF HEALTH r , (Y� Vital Records Section Burial - Transit Permit Name First Middle Last Sex Wk TgAdi Mg/ssNER FeM46 Date of Death Age If Veteran of U.S. Armed Forces, :>: H,42 .20/ 2 qt War or Dates a/ZA I Place of Death AHe- I/MI.44AI,LAX Polo, Hospital, Institution or AA.c• ONLICht, City, T_o or Village � l EG,�q Street Address l TS- QGf0 lILJ 7A24, - Manner of Death © Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined El Pending t Circumstances Investigation ill Medical Certifier Name Title '.6"Rb/LAN M42SJ1ALL A/ °- C Address pl /dre". aLA ,-i' i rkey /La, IAki "d9 CA AO ., Ny / 91( Death Certificate Filed District Number /5 0 Register Number Rii -fty�ow>r +Merge A10/Z- 5/ 46G134 ['Burial Date Cemetery or Crematory A142GN t< a.D/ A/.vg //IAJ ��2�/'1 ATO1t ;/ ❑Entombment Address <; ]Cremation 02/ oeiAK Z, c) 62d€Gnjwt,-5 , Ail/ Date Place Removed Z❑Removal and/or Held 9. and/or Address H Hold 0 Date Point of Si ❑Transportation Shipment G1 by Common Destination Carrier Q Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home /y,8 et/j/ /L hive . C/0 7S-- Address 310 S'A zA/v/9 c eV/. LA,et 'ell G,D. Ai /a.3 94 Name of Funeral Firm Making Dispositidn or to Whom Remains are Shipped, If Other than Above 2 Address M W fl" Permission is hereby granted to dispose of the human rem ' s described above as indicated. Date Issued 3-6-aO/A Registrar of Vital Statistics ) tL4 (' Ai / z -j(. (signature) District Number /50 Place �wm/ or Ali;e_ H E u3i9 !-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z at Date of Disposition 'Awl_ 1�Oa_ Place of Disposition „..tUtew s�ca_ 2 (address) tii CA C (section) I (lot number- (grave number) a Name of Sexton or Pers n in Charge Premises 1^t'�� l"'�� z (please print) La JV� Title Cr �1 TO Signature (over) DOH-1555 (02/2004)