Pratt, Patricia it 7NEW YORK STATE DEPARTMENT OF HEALTH 4 ti 7C1
Vital Records Section Burial - Transit Permit
Name First 0 i MiddleLast Sex F
RA r ,CAa A1nn P n 4'
Date of Death Age If Veteran of U.S. Armed Forces,
10 , 01. `1201 , ? S War or Dates
Plac- • -=-ath Hospital, Institution or
Ci Tow, or Village C%con Street Address 13 Gc j \,C c-2-61•
Manner of Death CA Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El 1-1 Pending
4,1 CircumstancesInvestigation
Medical Certifier Name cA,kTitle
ocv
Address 1 Z d 31_, » Cat NO C 1 C tie e K. , N1 I a'53
Death rtificate Filed 11 District Number c- Register Nu ber
City, own r Village c:\co() 5 ._) 1
❑Burial Date ® I o ,Z Ce tery or Crematory
ZO t i ne ,eA j Ccerncz*
❑Entombment Address n i
`-4Cremation QuaVa„ Load ) QLAPensfir'. . PI 1V Y`J
Date Place Removed
❑ Removal and/or Held
# and/or Hold Address
Date Point of'
o.
, ❑Transportation Shipment
by Common Destination
Ct Carrier
ElDisinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
s Permit Issued to / Registration Number
Y�
Name of Funeral Home I' Pj K. )mes �-1�nerc l bme. ONO-4-9
Address
'Cga QCl.c4 roc* CoLicAr4 Fy tZ6 __
Name of Funeral Firm Making Disposition or to Whom
rz. Remains are Shipped, If Other than Above
Address
a: Permission is hereby granted to dispose of the human remains d escribed above Vindicated.
Date Issued /D�a IS( Registrar of Vital Statistics /t) P•
( (signatur 0-1---.'--
District Number fj 5- f Place ---/-0-lt04._el Alue_ i___ vv
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition /D f tliL Place of Disposition t'& .,_,, it"a..t..�
(address)
(section) (lot nwnber) (grave number)
Name of Sexton or Person in Charge of Pre ises "n' `-��""
(please pnt)
W Signature Title rtl-1114_
(over)
DOH-1555 (02/2004)