Ritter, Kay a - -C/7
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
Name First Middle Last Sex
KCAV e Rt . -� R,T,Ci1e
Date of Dea Age If Veteran of U.S. Armed Forces,
- 101- I 7 4' War or Dates N6s
Place of Death Hospital, Institut or
Z`Cit Town or Village G yetis I-a 115 Street Address �efls (((S 1-;050fi I
r anner of Death Natural Cause ElAccident ❑Homicide ❑Suicide ri❑Undetermined El❑Pending
W. Circumstances Investigation
W Medical Certifier Name Title
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p.eiddress _
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Death Certificate Filed District Number Register Number
City,, Town or Village G )C ilk 1 0 it b 5iC1) I I ,S j
❑Burial Date metery or Cremat ry
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['Entombment Addre
'®Cremation C LI-C(LtlSblk J N
Date Place Removed
Z Removal and/or Held
2 a and/or
� Address
to
Hold
0 Date Point of
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Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date . Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home f t 1)-t- -FL.)-(4'-cd -- c ru f ) ne.... ( },) 1 I
Address
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Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
CC
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` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3) ( 3 (t 7 Registrar of Vital Statistics wCA Q
(signatur )
District Number ®/ Place 6 S k \s c
`'` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z I Date of Disposition 3I 1 5(i7 Place of Disposition d,n
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(address)
11.1
VI
cc (section) (lot number) (grave number)
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t Name of Sexton or Person in Charge of remises has J t"�►l�"
Z ,/j (plese print)
la Signature 1 th+P� Title in:n1n g.,
(over)
DOH-1555 (02/2004)