Orr, Joseph b-a').
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section x Burial - Transit Permit
Name Kirst y, Middle Last Sex
aefrco!, th I Agef7/ If Veteran of U.S. Armed Forces,
War or Dates /95-9 — /9 ic,•3
}- Place of Death Hospital, Institution orin
Cityiiii , 'dittage� Street Address ALCe,� )..eta,
/l���y
a Manner of Death Natural Cause Accident Homicide 0Suicide Undetermined Pending
U.1 Circumstances Investigation
ill Medical Certifier Name 2 Title
Address /e ' ^4e (/
Death Certificate Filed 3,... District Number Register Number
City, ��e , 6,Q/ c5 9/
['Burial Date Tr. Crematory
❑Entombment 1� ,.P-7- d(� '
Address
ACremation / k-'(�J •
Date ` Place Removed
• Removal and/or Held
2 and/or
�; Address
Hold
CO
O Date Point of
Di❑Transportation Shipment
ci by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration
Name of Funeral Home'iyN+� e -3
Address 2g q
/( Y- Q r
Name of Funer Fi Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
tr
to
` Permission is hereby granted to dispose of the human r mains described bove as in cate .
Date Issued .)7-06 Registrar of Vital Statistics G `<__
(signature)
District Numbery60( Place 1 1-Ce-ggi
I certify that the remains of the decedent identified above were disposed of in accordance with is permit on:
Z
tit Date of Disposition it /.)i/b(, Place of Disposition �,ntv.r„- Crt.rn gf ors y,T
2 (address)
Ina
tfl
CC (section) (lot number) (grave number)
ta Name of Sexton or Person in Charge of Premises C. h n S SPA a ett-
(please print)
i Signature (� Title CI-el).
(over)
DOH-1555 (02/2004)