Freihofer, Carol i 6C
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
RDL- l of A\ F
Date of Death Age If Veteran of U.S. Armed Forces,
(,- (:,—%c c (, `7$- War or Dates
▪ Place of Death t-to o C.l.'F.�.)£CILL-Pt.-ER 1` Hospital, Institution or
City, own or Village Street Address moo '� -
Manner of Death 1�71 Natural Cause 0 Acci t 0 Homicide 0 Suicide Undetermined Pending
�'�l Circumstances Investigation
iii Medical Certifier Name Title
3 4-. i- Eft_ i L- ._fi-R t 'M-Z
Address
l 0`3- (P PrCkk.L \ g L.E NIS r ''Pr US N-y.
Death Certificate Filed District Number ' Register Number
City, lawn or Village St)
iiiig['Burial Date Cemetery or Crematory
❑Entombment i NiV \EV-) C RV WI.Kroly
Address I
®„Cremation
Date Place Removed
Z❑Removal and/or Held
and/or
F; Address
Cl),
Hold
C? Date Point of
Cti
❑Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
111.1 ElReinterment Date Cemetery Address
Permit Issued to in C, Registration Number
ii Name of Funeral Home S"-"-- 0 e-c)\_@ v1JFA-t` Ho► € 0 1'1. \ 0
>iii Address
`\o 01%k-c0—AL-ln" Ste. —L-.ct **c e. E c K&f . *e.2-"-1, ---
iiRD
Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above
• Address
to
fl` Permission is hereby granted to dispose of the human insre ! described abo as indicated.
110 Date Issued /d� Registrar of Vital Statistics
/�
(signatur
!lip District Number,L Plac' _,aC—
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.F..
Z
ter Date of Disposition 6 _ S-"O 6 Place of Disposition Pi A,/.e L'I/ w C A. f-T ,Q'
(address)
LEE
ta
CC (section) (lot number) (grave number)
• Name of Sexton or Pers n in Charge of Premises th re 4,/I-t I top('
Z (please print)
ILI
Signature Title ('i Q WI p-ro p
(over)
DOH-1555 (02/2004)