Davis, Kara NEW YORK STATE DEPARTMENT OF HEALTH • R 13 :
Vital Records Section Burial - Transit Permit
<> Name First k/ Middle 'Last ex ,
V CtVa. M , 11/i5 t-e_WIC ,,
g Date of Death Age If Veteran of U.S. Armed Forces,
..„. S- 1- l0 - War or Dates _
Place of ath Hospital, Institution or
Ci , ovkm r Village Street Address �j 1- 1"-1-9
Ma of Death Natural Cau �<►/ Agent`'1 Homicide ❑Suicide Undetermined - 0 Pending
Circumstances Investigation
Medical Certifier Name - Title u
�t a h 1 uir h CVotA
Address vt Cc))
�` ' , ,
5 '- ' ,•off ��,t, ') - `i a�
iligi Death • •cate Filed District Number Register Number
IIN City, ow o Village yew kr-D.--
' LeS'i • ` c
Date CwRetery or Crematoryr.\
❑Burial -S q.•-Z)40 Yi h e_il i L� lXR-Y1A-c..02
Addre
Cremation r-l1,,� CY Qt-t._,-e..-e_v--> ki..-Lie--6.____,
Date
1 Place Removed
Removal • and/or Held
9I—I
and/or Address
a Hold •
0 Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
-'-' Disinterment Date Cemetery Address
:: Reinterment Date Cemetery Address -
Ei Permit Issued to ' Registration Number
ini Name of Funeral Home .v�1�yl oY t✓ %vk2a(u- e _ d CA4 SS
Address
Li Name of Funeral Firm Making Disposition or to.Whom
Remains are Shipped, If Other than Above
Address • - .
f
t Permission is hereby granted to dispose of the human rema' described above as i dicat
\~Y Date Issued S-4- 7)(a Registrar of Vital Statistics �5V-.A-fr &.
/lam (si
<`< District Number Place ` D 6 titek
I certify that the remains of the decedent identified above w• : disposed of in accord. •-rmit'on:
f
Date of Disposition 5 A 16( Place of Disposition P,n:v ;•t - r
2 (address)
itl •
C (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises ( k r, ) Se e,n,t,ti-
/� (please print)
al Signature ( 1lt1.-, wry Title
(rev). a i
(over)
DOH-1555 (9/98)