Rutherford, Betty NEW YORK STATE DEPARTMENT OF HEALTH ' _.. 1 °H t 3r
Vital Records Section Burial - Transit Permit
p
Name first Middle Last Sex
e 9 ---hey-co rc1 I F
Date of Death I Age f If Veteran of U.S.Armed Forces,
.Q ( 1 12011 1 P Z War or Dates
: - .ce of Death G �� 1 Hospital, Institution or � ��S ��� �P�,�
�Ci Town or Village U_AiNC LI ! Street Address
rjiR Manner of Death Cause 0Accident Q Homicide :__I Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name moos\ ( x0 1ma_ Title M 0
4Addressll)ico ?ark sfi Iva s fa , ivy 1-2 0
-===>x Death Certificate Filed ; District Number j Register Number
t e)Town or Village U S cCL S 6 o1 I 3 0 7
i Date ( Cemetery or Crematory,, ,
❑Burial ! V IS) I - P1 ru V .('-3 ( Yeti(( it
Address j
VCremationl D-.>o\.,\Lt Q O\ C.-``Ve-t�-f J �, iY/ Z e 4 Li
Date 1 Place Removed j
-. Removal I and/or Held
and/or 1 Address
f Hold i
} i Date ?cint of
Transportation i i Shipment
mmon Destination
Carrier ?
::::-,—., r.='u Disinterment I 'Date Cemetery Address
Reintennent ' Date s Cemetery Address
1
Permit Issued to I Registration Number
_ .: C'�all•er ¶une(Cxl \Aoln� ox 130
Name of Funeral Home ,
Address
I `\ i...-o. 1 ems- kr-e ea- Q v.eenSb .r'j 1 N'f 1 2404
o Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
i Address _
Elm
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/ 5`17 Registrar of Vital Statistics iC 1,-.V
==1 (signature)
iik District Number_{j ',Q I Place 6(XJS A 5 i P' l
1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
E Date of Disposition ( /71 n Place of Disposition Fi n 11 t`w 'm`vt,(AIN--
a (address)
EEI
ti)
M (section) ,>Elot iauniber) r" ,.(grave number)
0 Name of Sexton or Person in Charge of remises C' 'c `FC/t+4� J in4!�l
(please print)
Signature �( Title CIE m N.
(over)
DOH-1555 (9/98)
I