Whinnery, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH a
Vital Records Section Burial ® i ransit Permit
` Name First Middle Last I Six
U d .D i I i9MC WM^I N v I /_tr/YdLLr
Date of Death Age If Veteran of U.S. Armed Fors, Q
/ I7 I-7 I ar Dates �I-
o of Death (� (�' Hos ital I itution off Fink,
�
:, s 'own or Village C1 (,(a',.rS / e2LS Street Address �` t, ',..i s / in ,S
C:i. Manner of Deatfrf j Natural Cause 0Accident (l Homicide Suicide Undetermined n Pending
la �l Circumstances Investigation
u Medical Certifier Name (- PL.,-5-12
Title
0 A 7-640/ f ) i ZZ6-LL( "It 11
Address --
`� PACc;--. cter,sfx l/ /ha_S /v�1'
y / Z c- 0/
Death Certificate Filed 1 District Number Regis er ber
City, own or Village Q CC3�3 Ftr7Z�S ` t�
Burial ! Date / / Cemetery o Cremato fi
/A c.).- iii t..q-z--)
: ❑Entombment Address r
cremation Q /97L UeW Q U -�-(Q /vy
Date Place Removed ( ' /
Z — Removal and/or Held
—and/or Address
to Hold
0 Date Point of
fik❑Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
>< Permit Issued to Registration Number
Name of Funeral Home A/:-\c c cr\ Ho w C' 11 G
Address
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`1 t___C:..�`[�.� �—ac- ��; C �1��Jv� � r Icy !Z C
- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
III
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t I i Sil 7 Registrar of Vital Statistics 1
(sign
District Number 560 ( Place G (Q 'c- A \ ` S Ai l7
E. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
pp
la Date of Disposition I`/za ill Place of Disposition ' int lite-1 (,-' n4'toc Iry
2 (address)
01
I (section) lot number) (grave number)
0 Name of Sexton or Person in Charge f Premises ��ri s�flp�r �1't 4 t f f
(plea print)
t, S Signature Title CREmftlaf
(over)
DOH-1555 (02/2004)