Davison, Katherine it Sri,
NEW YORK STATE DEPARTMENT OF HEALTH Burial v Transit Permit
Vital Records Section
Name First 1� Middle Last I Sex 7.
• C- i N >Wikfti
: Date of Death Age �I If Veteran of U.S. Armed Forces,qi
�/q/7 I 31 I War or Dates
Place of Death os , Institution or
z City, wr r Village QusJU, ryreet ddress 1jfall-C
raManner of Death❑Natural Cause El Accident 0 Homicide D Suicide ri Undetermined ((Pending
I Circumstances 'N Investigation
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al Medical Certifier Name Title
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Address S Z Hot v i land . Cis i t is N y I VO I
Death Certificate Filed 1 District Numbe? QI Register Number 367
City,T1or Village DIA y D(DM
❑Burial I Date q_J /Zo /� Cemeter Cremate f . IYIlli
gEntombment Adcjeait1 , col QUI-0/0E641i N (2�o
Cremation )) •
Date ' Place Removed
r CRemoval and/or Held
and/or I Address
Hold
(11
0 ' Date Point of
Q Transportation Shipment
9 by Common Destination
Carrier
I Date Cemetery Address
:::?❑Disinterment
[]Reinterment
I Date I Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home L,\I1e-"c L ilk<Z'..\ -\oc k- C~'t l 0
Address � _
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the humaremains describ d above a ind' ted.
' Date Issued Registrar of Vital Statistics ��/_.yr�li'L lei -(
1.
�° (signature)
District Number /'
s CIS) / Place �;e=-�'—'�'�' �C�
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I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on:
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Place of Dispositionest `vrnaslvri
ttd Date of Disposition 7�/0 in
(address)
ill
tocc (section) (lot number) (grave number)
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Name of Sexton or Person in Charge of Premises ` 's '� 'JH"'`
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L1i, Signature (�( Title �l`nhi
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(over)
DOH-1555 (02/2004)