Flint, Kimberly Ann Fes+
NEW YORK STATE DEPARTMENT OF HEALTH
1
Vital Records Section Burial - Transit Perm t
Name F'rst � idd(Ile Last� ��
mo
Date of D �thl Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 21 CF'll. irC*1 'Ye; '
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
_ Circumstances Investigation
W Medical Certifier Name Title
��suh Lc�'rnkxxS �
Address
1
Death Certificate Filed District Number Register Number
City, Town or VillageQA(( ( D
❑Burial Date ZD Ce ry or Crematory
❑ itvu
Entombment v
Address
Cremation
Date PlaceRemoved
❑Removal and/or Held
and/or Address
Hold
8. Date Point of
Transportation❑ p Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registrati n N tuber
Name of Funeral Home 5 it;("4Qr'Cj I�L'-
Address
O
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
Permission is hereby granted to dispose of the human rem esc ' id a 'ndicated
Date Issued 3—IQ-2 Ckegistrar of Vital Statistics
(signature)
District Number (, SO) Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I- Date of Disposition 311 17,o Place of Disposition
a (address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premi es 1+O ' r•A
(ple a print)
Signature Title "hlUfl
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 13 3 Q 3
Receipt
Human remains of delivered on , 20
f'
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#