Kilmartin, Elizabeth v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
si Name First Middle Last Sex
Eli ZAhe-rh an4 H11 M42Tii9 reiiikIc____
in Date of Death Age If Veteran of U.S. Armed Forces,
Rea.ICt J'9- 8(-I War or Dates
• Place of Death Hospital, Institution or
City, Town or Village Street Address
III0 Manner of Death IK Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
La Circumstances Investigation
ta Medical Certifier Name Title
41 &(P A) Blood ri• D
Address
Death Certificate Filed District Number Register Number
City, or mow Village Quirrils)arc y 5 4 5 '1 E5 3
]Burial Date Ce etery or/Crem3 ry
['Entombment Address 5i 2017 i&it V PGc2(. (TE2/
Address
Cremation —
Date Place Removed
3 ❑Removal and/or Held
and/or
F: Address
{/)
Hold
O Date Point of
sTransportation Shipment
O by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home D' KEJL �je ti // gi'lie
ig Address
li LAFt-y7.( s', L eivstuT N v/,co/
qo Name of Funeral Firm Making Disposition or to Whom
14, Remains are Shipped, If Other than Above
• Address
cr
la
m` Permission is hereby granted to dispose of the human remains described above as indicated.
giii Date Issued t)Ay ) odd l? Registrar of Vital Statistics - -% k - c'. e ,
(signature)
District Number 5i Place&um l wy Jinokix / k artivchlar0//02:71
'' I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on:
tl Date of Disposition 5 J(13((1 Place of Disposition, SI Qt.k4 k i--- ck, U.E e-iitSct.t.A-L.4\4 ( r ) `�•
Ili
fa V 1
C (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of P emises f
.(._
(plea print
____ j` Q.A
Signature k -(/D�.. Titl
V
(over)
DOH-1555 (02/2004)