Kuhn, Werner NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
t/V\
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates LCCVZ2
Place of Death Hospital, Institution or
City, Town or Village ' a t, c,;,wr Street Address �,2
Manner of Death ®'Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
L %7,
Address v
Death Certificate Filed District Number Register Number
City, Town or Village -/ 4l X{7�„r;;v 01
Date Cemetery ol Crematory
❑Bl uria �i%.� %,a `/� v ,� -e
/ Addre
G/
2Cremation e. �y.
Date Place Removed
Z❑Removal and/or Held
... and/or Address
Hold
Q Date Point of
JIL
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeJGAIV G/ G
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is here granted to dispose of the human re ins described above as indicated.
Date Issued �` 2 Registrar of Vital Statistics,
(signature)
District Number %>J� Place �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of DispositionW.
(address)
LLJ
M (section) (lot num er) + (grave number)
0 Name of Sexto or Person in Charge of Premises �-n��� �(f
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61