Stapp, Christine IZ/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name first Middle Las �x
�/2/'5 7c? �e p/o;%7 S J`i/-/ p rOL4i164-
Date of Death Age If Veteran of U.S. Armed Forces, �D
iiii yi--/ - .2.6(�f 6.3 War or Dates
Place of Death` Hospital, Institution or �/
Cit Town or Village 6 15 f6 S Street Address or,
.s��7/s/v -
Manner of Death Homicide Suicide Undetermined Pending
Natural Cause ❑Accident ❑ o ❑ ❑ ❑
Circumstances Investigation
Medical Certifier Name Title
ra§:
Address
i Death Certificate Filed District Number Register Number
gg City, Town or Village
Date Cejlery or Cremator,
CIBurial 5 F-O 1, fr?ev,'t'ests 6--/Q-r'`u g---7e)e-ziu'Ai
Address //
�� Cremation ..w d ir &�-P.P �Slbc.1`2 y
Date Place Removed
0❑Removal and/or Held
and/or Address
1 ; Hold
e Date Point of
w❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
ie Permit Issued to Registration Number
Name of Funeral Home i I Svn e•-6 e 7 /- f2I-IC D D ?3/
W.
Address�;�;'.a s r2e- (/ �ililL:7 4 mil/ /J y L / ,,?y (f-7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
bR
Permission is hereby granted to dispose of the human remains desc 'behd above in to .
iiiiDate Issued 3—�t-U Registrar of Vital Statistics
(signature) _//
District Number �o(i` Place / /-e,t-�o `�-7 / A'`>4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
��--o 46vj4(tc.) .r'— '4O/ &) - -z
Date of Disposition 3-0-Der Place of Disposition ��
(address)
CA (section) lot numbe (grave number)
CName of Sexton or Person in Charge of Premises C9-1 y f°4� 7
9----(please print)
Signature Title Ci At(4tP/
(over)
DOH-1555 (9/98)