Andrews, Kathleen t ‘/N it
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First dle Last \ Sfix
M M 1 fin` =-MO,' \\.(x-N A�&Ce�S L'Mc�-\ .-
Date of Death t,5 _`csv Age \is If Veteran of U.S.Armed Forces,
War or Dates
Place of Death '`' Hospital, Institution or
City,Town or Village �K�- Q Street Address 1 i 1I\S1 I tJ CS go AO
Manner of Deathp Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name rR OAS ^ \ Title (\ 1_
NYl '1�C� �'t���•Nar. �'1t.'r3•C:vG-<-...
Address .. ::), x Sk. �0.2C.� \Cr ;c31\.\c,N.,1
Death Certificate Filed \1- District Number Sq RegistecNumber
City,Town or Village 1-'�`. Corp
❑Burial Date cf - ;� _ \ Cemetery or `ematory ��\ ��
❑Entombment Address ' \
.s.\.
Cremation �� �e'n5d7J� 1 N
Date Place Removed
❑Removal and/or Held
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 Home ' N C(\eT 'c cuyvk
Address \�� INAU,v . 'D� - 'Z:__ i\.)\ \2-c6CA
Name of Funeral Firm Making Disposition or to
Remains are Shipped, If Other than Above
Address
Permission is he eby granted to dispose of the human rema s es 'bed able-- ,s indicated.
�- it. , (cVV`C__
Date Issued K - Registrar of Vital Statistics
(signature)
District Number g� Place [-ktkr Lck
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition B A li Q Place of Disposition feu err sly
(address)
(section) (lot n ber) (grave number)
Name of Sexton or Person in Charge of Pref�tises r+t°pt''�' �a,
44-
A / (please print
Signature �(/{� Title l ''"WA-
(over)
DOH-1555(02/2004)