Kaudern, Bertil NEW YORK STATE DEPARTMENT OF HEALTH ` .
Vital Records Section Burial - Transit Permit
Name,. First Middle Last Sex
r-r--1-) I LI f<Gt u Cle-r V\ R
Date of Death AN If Veteran of U.S. Armed Forces,
)a OlS—(i War or Dates M n
Place of Death Hospital, Institution orii P&riI
v ,, 1
City, Town or Village V1C LO I/ Street Address 17 'j_T C c ' r I uJ ..
Manner of Death 14 Natural pause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier n u Ss 1 I P „ /, Title
1c. l C 'V'
! Address�
NIDeath Certificate ilecN i District Number Re ster Number
City, Town or Village o�/05� 1,bf15Ids ao��,
El Burial Date I �� 1 J Cetery orCrematory `i
DEntombment Address iv) ' �j
07 Cremation (ILOS ljtk
Date Placemoved
❑Removal and/or Held
and/or Address
" Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment
Date Cemetery Address
Q Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M t\ex- 1 V'' [ .�-,0 vQ 0I t 6t9
Address
6'56-1 i\kl---S' RIK 5r) 1 na Ail Li IC_Q IVkt I 614-2—
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ains described above as
indicated.
Date Issued,/a�6p ,R,o rg Registrar of Vital Statistics �aE1(i1 , �1(J0-4 c�-(Y
/ (signature)
District Number A 7. 1�5 Place C kQ- / w/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition )="'d-7—lc/ Place of Disposition i)i pt., VI Vt) G Ce-4`9_l c
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises J r'fr",V,' SI.
,(please print)
Signature Title C f4,ra
(over)
DOH-1555 (02/2004)