Feulner, Donald F. NEW YORK STATE DEPARTMENT OF HEALTH _ itI(/2
Vital Records Section s Burial - Transit Permit
Name Firs- Middy ,Last Sex
o k l fi . ±e L.ne,r- /✓)K L�
Date of Death Age If Veteran of U.S. Armed Forces,
I l/7/a 3 .. / 1 War or,Dates
1- Place o eath Hospital, Institution or
Z Cit , Town r Village �or;,,-y I� Street Address
w 7G9- C . 0.77 `t
p Man r of Death Eli Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
UCircumstances Investigation
tU Medical Certifier Title
Address/
`a,� PIN.-41",,1 6 ,...� -Rol,- , N T ►a wl
Death C to Filed ( 1 District Number Register Number
Cif, own o illage Cot t�� a. y-Sc--- ,750
❑ nal Date Cemetery or Crematory /'
i / f o 6..23 , ne'it:c(,.e C_(t,..,�—
❑Entombment Address
®Cremation 0acen- bar J N2 7
Place •
Removed
Date J emove
Z Removal and/or Held
O❑and/or Address
0 Hold
O Date Point of
cn ❑Transportation Shipment
rz by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date " Cemetery Address
Permit Issued to T +— Registration Number
Name of Funeral Ho n�e1�c' 'c �L-n er1- 14 t � p 0 `t 5�f'
Address �J���J
7 [/'�sr� Ave C� !'�'t I y
Ia is )_
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
2 Address
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tU
0. Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued I I /i,3 7i. Registrar of Vital Statistics 42,eite/C)
(signature)
District Number y -5) Place CJ( -, _ NI j
I certify that the remains of the decedent identified above were disposed of in rdanceh this permit on:
W 'Date of Disposition It to/W Place of Disposition hl� ��`►
2 (address)
W
U)
cc (section) ar,;(lott.imb -e#s---- (grave number)
Ca Name of Sexton or Person in arge of Prem. s evkAiii
Z (please print)
Signature �- Title fD,^" at
(over)
DOR-1555 (02/2004)
Public Health Law Sec. 4145(2b) 014184
Receipt
1
1
Human remains of delivered on s • , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#