Schoonover, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
iiiiIii Name FirstGis) Middle
................. •
•
........::... . ..
< ::; Date of Death Age If Veteran of U.S.Armedorres,
• 5?. ./. .C... .... ' ` War or Dates
.,. .• Place of Death `' Hos ital, Institution or
- . -- - .----- ...-:-...... ----...-.-.-:_-. .
tj City,Town or Village � Street Address
12. Cause of Death
is,f i0\A-e4-
A.A...k...../
Medical Certifier Name v Title
......
Address
•
:<s Death Certificate Filed District mb r i0:,/r-tAt--)) in- 'k I
Vetter N ber
City,Town or Village 4664j/ 14 o/
Date - Cemet or Cremato
urial 4
❑Cremation I Address
Oi: --77.a., (1, ,
,= Date Place Removed
Removal and/or Held
/or Hold ' ::::::::::::::::,.:::::::::::::::::::::::::::::::::::::;::::.,.:::::::::::.,::;::::::::::::::::::::,::::::::::::::::::::::::..::::::::::::::::::::::::::::::::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::
ih and Address
IL Date Point of
•;in ['Transportation by is Shipment
4.71 Common Carrier
Destination
Eg
::...................................................................................................
Ki, ❑ Disinterment Date Cemete Address
.................................................................................................
dress
❑ Reinterment Date Cemetery A
ii
iii Permit Issued to Registration Number
) /221-1--A-kr"---- - ep,„7,6-,„.., „„.0.,„„,
Name of Funeral Firm . ..... .........................................................::.::.:.,..::::::: ::::.
Iiim Address
‘7 re___.,4 j2,f 39:,Z4J
Name of Funeral Firm MakingDis or to Whom �..
::�*:; sition Po ..
'"" Remains are Shipped, If Other than Above
------
mi.
Address
Permission is hereby gr nted to dispose of the human remain described above as Indicated.
ign Date Issued o2 Registrar of Vital Statistics °' --it i,0 , /6 ..-..
(signature)
€ii District Number 4 Place r ��--14-'J 4,)• . / `) /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition . -1- `s'f Place of Disposition s> . rt,'iI
u1;; (address)! S
(section) (lot number) (grave number)
;fas
;;;a.: Name of Sexton or Person in Charge of Premises C.,,.... a.....
(please tom)! . Signature / �' �
Title . '`"1.1(;,.u..k. L.°%12_l-',----c2-1
DOH-1555(9/86)p 1 of 2(formerly VS-61)