Bartlett, Annette NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section _- ti Burial - Transit Permit
Name FirstA A� 4 ti ziddle .8,4 -� 1 Sex + }
e.'
Date of Death / Age If Veteran of U.S. Armed Forces,
i '' / 4,a i g 1 o 1- War or Dates
} , Place of Death Hospital. Institution or D /�
, City, Town o i a �r.n- Street Address 3�S- Y R t I-Er Axle_
p Manner of Deatr Natural Cause Accident ❑Homicide —Suicide 7 Undetermined Pending
11, Circumstances — Investigation
Medical Certifier Name Title
q 69 67,C S^ K'4\, flA 1)
Address
. 60 P4i r Avc Cr'n "&rh) NY Z 8 a-
Death Certificate Filed District Number Register Number
City. Town or Village Lp!`, ,t,-Lk 471-553
Date Cemetery or Crematory i
Burial V l 6// o)of `� �/ -6r
��77yy Address
L l Cremation a A s.b LA-r c ' T,r4
• Date L Place Removed
0 Removal and/or Held
H and/or Address
- Hold .
O Date Point of
0 `Transportation Shipment
a by Common Destination
Carrier
• Disinterment Date Cemetery Address
C Reinterment Date Cemetery Address
Permit Issued to �r f Registration Number
Name of Funeral Hom GA a 1 (.•tnet� t't '---- Dv `t`f'(
Address
erg., AK-- . J% /)V.)i
Name of Funeral Firm Making Disposition or to Whom
~ Remains are Shipped, If Other than Above
Address
U9
Permission is hereby granted to dispose of the human r atns scribed ov s' icated.iii
Date Issued f , lo fie Registrar of Vital Statistics .(A4_
a re)
It
District Number 'c5� Place [, ar•'1 J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ,,//
w Date of Disposition lint If Place of Disposition ��►,+i�� /�►r
.. (address)
uU
CC (section) dot pumberr (grave number)
0. Name of Sexton or Person in Charge of Premises i M1 it
Z (please print)
W Signature Title *AO?
DOH-1555 (10/89) p..1 of 2 • VS.6)