Ort, Clara NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name �jrs� /C /Middle LastSex
itk
.,. - Date of 0-ath Age If Veteran of U.S. Armed Forces,
// & Q/� 9 , War or Dates
Plac• • •e h /T Hospital, Institutio or
Ci Tow \or Village -/6_f LF Street Address f'/EA1 Sf}.OT `j/- '7 y /iV 70e,i- !/ll
al
c Manner of Death pm Natural Cause Accident 0 Homicide [Suicide Undetermined �Pending
Circumstances Investigation
at Medical Certifier Name Title
fr. 10If 5 &-
Address /� /� /
[ // v''V R ,q l� /4/t d /c y J; 3/
Death Certificate Filed District Number Register Number
City, Town or Village sj
>`' �Burial Date //// C/gq(letery or Crematory
[]Entombment `'/ vVp2o/-- l7'`i� [//T)4) (,�i/V/? 9
Address 1�
,< [Cremation 6/c-t6b-Alite, , V
Date Place Removed
[Removal and/or Held
w"
and/orHold Address
SDate Point of
Di 0 Transportation _ Shipment
a by Common Destination
Mil Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 4(7/ s,//4j //Cy/ /
a
Address
::!iiiiiii . -__Y (V4ill, Sl— 6 -47/(/‘//e-L6 )01 72Y,Y?
illi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;;' Address
; -
• Permission is hereby granted to dispose of the human r lns deJcribs above s dicated.
Wil Date Issued i1 ; �3 Registrar of Vital Statistics Q�(i,,Q f i /k- ti -':*
(signat ill ure)
)
District Number 5 7 ) Place`- (,'/ 0/7; c c, -
I certify that the remains of the decedent identified above were di d of in accordance with this permit on:
W. Date of Disposition / p b/tJ Place of Disposition /;i+' %C1,J r
-?4vt4_ ,a (24.kz-AL;dq,�,
Jdrfrss)
?
l (s lion) (lot number) (grave number)
xto� C�,Ua1,G �j
Name of Se or Person in Charge of Premises 14 -%f
'" ( ease print)
Signat re /4 e tr Titl .�cr �t
�.. tl
(over)
DOH-1555 (02/2004)