Barrett, Susan NEW YORK STATE DEPARTMENT OF HEALTH Z7 J
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
S la r) &I (`re l !{�_YY cit"c
Date of Death Age If Veteran of U.S. Armd Forces,
Mii 4- 3 - clo l 5 B War or Dates r�
j Place of Death /�' Hospital, Instituti Nr
+' City� l�k It
Town or Village S Street Address (er 05 - ia,'
iti Manner of Death Natural Cause Accident Homicide ❑Suicide ❑Undetermined �--Pending
tki Circumstances —Investigation
AI Medical CertifierA .�Napin a n Title
v Addres
v c. -
c (Ls
Death Certificate File District NL?mber Registe umber
{<: Cit , Town or Village�k(,ns r s$ 5(00 I oO t
Date metery\gr Cremat
❑Burial 04 /04 /iX' 11 LY}f. W-eu)
Address
®Cremation t,(,Qs2.,,nc- b
gDate Place Remdved
ia❑Removal and/or Held
•- and/or Address
�"" Hold
0
0 Date Point of N.
�' Transportation N❑ P Shipment �,
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-
Permit Issued to r Registration Number
Iii Name of Funeral Homer --tuAkra( fltQ( )n G c.1
:< Address
11.11 01+ ChurCh St- L LuZe rr4 Ny ag-
`` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
»> Permission is a eby granted to dispose of the human remains described above as indicated.
Date Issued ' 11 Registrar of Vital Statistics L'OCk U...),./1/4-"t
signature)
<' District Number Place 0 t D t- G lens �(t lis
I certify that the remains of the decedent identified above were disposed
of in accordance with this permit on:
WDate of Disposition qi 5f n Place of Disposition ghi,Dit..; Cv.,r ,f 0rA--
W (address)
0
GCC (section) llotnumber) S4 (grave number)
Name of Sexton or Person in Charge of Pre ises [ .ijot
F (please print) ]]
li ! Signature • il Title Ca ,/mpit
DOH-1555 (10/89) p. 1 of 2 VS-61