Carpenter, Ariel Talitha09/16/2019 13:04 5183773446-IGHTS FUNERAL HOME PAGE 0f1/01
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
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Name First Middle Last
Ari e. CQ.r
Sex
Date of death /
Age
if Veteran of U.S. Armed Forces,
/ ! q
D
war or Dates
Place of Death
Hospital, Institution or
City, Town or Village A 1 ba„
Street Address a I b G---�-�r
Manner of Death ZNatural Cause Accident ❑ Homicide ❑ Suicide Undetermined ❑ pending
Q I Circumstances investigation
Medical Certifier Name Title
C.. Q.SSOL'4 ,-
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Address
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Death Certificate Filed District umber Re ister Number
City, Town or Village IN ibeswOl
❑ Burial
Date Cemetery or Crematory
a Entombmer>t
Address
Q'Cremation
2. l
0
❑ Removal
Date Place Removed
and/or Held
.E
and/or
Address
Hold
�
Date
Point of
❑ Transportation
Shipment
by Common
Destination
Carrier
❑ Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
Permit Issued to +�
Registration Number
Name of Funeral Homey
Address
Name of Funeral Firm Making Disposition or to'Whom
'
Remains are Shipped, If Other than Above
Address
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Permission I((s��h reby granted to dispose of the human rem ' s describp4 above as indicated.
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Date Issued `"1 Registrar of vital Statistics
'
(signature)
N,
r .s
District Number Place
I certify that the remains of the decedent identified Albove were disposed of in acc rdance with this permit on,
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Date of Disposition fln1ij Place of Disposition�i0�ti �• tea..
(address)
ul
(section) of number) ( (grave number)
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Name of Sexton or Person in Charge of Premises
,�. (Pleage print)
Signature LLL Title
(over)
r iw-i rvr%r% rngr9nndi
a,
Public Health Law Sec. 4145(2b)
012540
Receipt
delivered on 1' —,20
Human remains of .*"
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License #'I k