Berg II, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs Middle Last Sex
�at
Date of Death Age If Veteran of U.S. Ar ed Forces,
CA- `( L War or Dates
Place of Death ��/ � Hospital, Institution or
City, Town or Village V 1��,� C a f.n 16t\� Street Address
Manner of Death Natural ause ❑Accident Ej Homicide Suicide Undetermined El Pending
Circumstances Investigation
Medical Certifier Name / Title
TT
6eDr CA e-
AdAs(j
r 41 ,
Death Certificate Filed J District Numbe Register Number
City, Town or Village J; 11a e CoP:n
Date�1 metery or Crematory
❑Burial 06-1�
Add ess
Cremation �� �, f
Date Place Removed
8 ❑Removal and/or Held
and/or Address
HOId
Q Date Point of
y Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ,�y ,J r� e
Address
Name of Funeral Firm Making Disposition or to Who(n
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human em s describ b, ve as indicated.
Date Issued �o �i` Registrar of Vital Statistics
signature)
s District Number
Place Ca / -1 L' z> Cie e/"� cc 4-0t: ti4 l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
— 11110
z Date of Disposition, M— Place of Disposition &/y.�
(address)
ti
� g (section)(section) (lot nu n j (grave number)Name of Sexto or Person in Charge of Premises
(please print) i
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61