Fliehman, George NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name first diddle Last
tz-1 Ma A
Date of D ath Age n If Veteran of U.S. Armed Forces,
War or DatesWry
Place of eat Hospital, Institution or /
City, Town o Villag rG✓1 Vl Street Address �J 1v�v2 GElN l 0PIE
Manner of Dea atural Cause Accident Homicide ❑Suicide Undetermined ending
A. Circumstances Investigation
Medical Certifier Name Title
A d ess
E 2 �,-
Death Certificat 116
District Number Register Ncmber
City, Town o illage i v- b
e CeFns�pry or Cre a ry l
Bur 1 U If 2Gc� e-Altapu bY�
Ad / �J-O o
Crem a ion t f3u.�c�
Date Place Removed
Z❑Removal and/or Held
... and/or Address
5 Hold
Q Date Point of
NQ Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
:::j-❑Reinierment Date Cemetery Address
Permit Issued to Registration Nu ber
Name of Funeral Home /✓�►1 /" �r10. ►Lc�+. q'
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
L�.
Permission is hereb granted to dispose of the human remains described above as indicated.
Gate Issued J &(o Registrar of Vital Statistics
( i ure
District Number or:u
Place V 1 C, t�(Ar)✓I
/X-
I certify that the remains of the decedent identified above were disposed of in accordance with
1 this permit on:
s� Place of Dis Disposition P/'l��//O W ag-k--Ad/ d
W. Date of Disposition p �
W (address)
UJI
(section) (lot m ber (grave number)
0 Name of Sexton or Person in Charge of Premises �
(please print) `� n S�
Signature � �
Title�� "�/► / �/
DOH-1555 (10/89) p. 1 of 2 VS-61