Rumsey, Karen /70J
NEW YORK STATE DEPARTMENT OF HEALTE.
Vital Records Section N. . . Burial - Transit Permit
Name First - Middle Last I Sex _
;<l Date of Death fJ / Age If Veteran of U.S. Armed F es.1J
Iiiiiii' / /S`/d Co S.9 Dates '9-
P - e of Death Hospita, stitution or
r;J/
W. own or Village LL. ,S. Fe- , ee Address �, L ./Js 92LS
Manner of Death1JNatural Cause El Accident 0 Homicide El Suicide ri Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name i 7 Title
_' Address
i Ai o r T/d- Cit6);Ic._ A) / 2 p-—
iiii th Certificate Filed District Number RegisterS
N mbej
Ci own or Village �.� G � S /- 3- C-c /�
Date Cemetery or em
: : ❑Burial L /a /.6 (p i ni V/E eit 6170Tb
Address jy! .
:.. Cremation u �E-,1,,1. i Q U L '�..3.� U i
Date Place Removed
❑Removal
and/or Held
! and/or Address
O Hold
O Date Point of
El Transportation Shipment
O by Common Destination
Carrier
Q Disinterment Date Cemetery Address
.:::. Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home fip7,0,912,N ', /RAro( 1-.;44 yi d t.ANC- 01)9 [l
Address
// / 0 — S; 0u /..IS t / y.
il Name of Funeral Fi rn Making Disposition or to Whom / -
Remains are Shipped, If Other than Above
Address
A
«<' Permission is her by ranted to dispose of the human remains describ above as in sea d.
u.
Date Issued (�Registrar of Vital Statistics fj� ,Q;Qe�� ,%r C
iiiM
(si ature) /,
<' District Number / Place /G2._-�/� -e( . SEC., /
iI certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
5 Date of Disposition LIM /0 t7 Place of Disposition P,nr✓ut,... Crtwq..'rorawry
2 (address)
iU
Cl)
Ix (section) lot number) (grave number)
Name of Sexton or Person in harge of Premises ( /N f I ! Sy r uk-
Z (please print)
W SignatureZ Title �r t m.,. C
(over)
DOH-1555 (9/98)