Cave, Caroline NEW YORK STATE DEPARTMENT OF HEALTH 5q9.
Vital Records Section Burial - Transit Permit
Name First Middle LAst Sex ,
CaroteAt M - I—
Date of Death 7 Age �, / If Veteran of U.S. Armed Forces,
P /OW-�,y - t� War or Dates N/(3""
t- Ple of Death Hospital, Institution or
6(:City)Town or Village acj iLtee p Street Address (,QS r 6t7)S . mcdica, ( ."-
a Manner of Death Natural Oa1se Accident 0 Homicide Suicide 0 Undetermined D Pending
W Circumstances Investigation
iii Medical Certifier Nam Title
CIi t!Ct Jan "Ui/( no �..(,0
Address
Death Certificate Filed '' /District Nuptiber Register Number
ity)rown or Village Pa. Q1f_09 p I3 --
❑Burial Date Cemetery or Crematory
Pit\--e IA 64) creined-Diy-
❑Entombment Address r1
'Cremation /LS f 0,1� AA
Date Place Removed
Removal and/or Held
P❑and/or
Address F
fa
Hold
0 Date Point of
tip❑
Transportation Shipment
O by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Q Registration Number
/' !
Name of Funeral Home _ rJ aarr riC , 0114l/0
Address
, ,3/ ) mar c five . L2 Le Piaci cI- Pgy(2
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
it
Permission is hereby granted to dispose of the human remains described abo,�(e as indicated.
Date Issued 1 / 3O -?O(‘;Registrar of Vital Statistics (( 1 '`-�'C'f�-� ,
(signature)
ei District Number Lia Place f , (^
J
1,
I certify that the remains of the decedent ident . above‘ ere dispo of in accordance with this permit on:
2 1�
LEI Date of Disposition i) /t.Z/Ub Place of Disposition t"t n.t v.t..J C rc kf„r i,. v`
2 (address)
W
tn
CC (section) / (( < _(lot number) (grave number)
IIName of Sexton or Person in Charge of Premises I. r% -X vi
.z (please'print)
• Signature Title ( ram Rfc.r
(over)
DOH-1555 (02/2004)