Moses, Kimberly j V. t IIZ
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
h friiher/Y f�C'S�S es 1 !Y,-.sn/�
Date,Qf Death I Age ; If Veteran of U.S. Armed Forces,
INII c S — cQ 0 1 7 1 A/3 War or Dates
• Place of Death I Hospital, Institution or
Iii City, Town or Village Alaod co ol./.�' Street Address ..S`y' 7 STA/- ,er d-Al
, Manner of Death 21 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
IM Circumstances Investigation
Medical Certifier � eanu P n 6o'� Tri,
ill 4T''
Address
la
V
-5 A,rt-j. a on1 ) o r1 u--- Id tees"6 eJ y, l - -5 6" "3---
Death ggflificate Filed District Number Register Number
City, or Village ( �i c c r' g I / S 5
Date I Ce�tery or crematory
CI Burial 0.2 - 9 _ o?0 /7 1 (y7 )e-Off e.N e,A/o fry
Address OF
[ Cremation
Date Place Rervfoved
0 ❑Removal and/or Held
rf and/or Address
Hold 1
Q Date j Point of
fik❑Transportation Shipment
5 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to �- Registration Number
Name of Funeral Home �-E3(it Eva A - 1 _/! r(J/Lf Ka l � �.,. U 0:57/
Address
1 ).y. i xe--7 0 .
4„.:::::::,:, Name of Funeral irm Making Disposition or to Who
;Li; Remains are Shipped, If Other than Above
4 Address
u
N
iiig Permission is hereb granted to dispose of the human remains described- ove indicated.
Date Issued ./6 Registrar of Vital Statistics jj(.6L . r k_j. ;
L (signature)si nature)
In •
District Number f IjI)(-/ Place )3ki„ w\l\-1 '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iTi p Iio Place of Disposition enic�etyJ (rrn�{oriw^Date of Disposition 1 �i7 p
2 (address)
UJ
C (section) (lot number)C (grave number)
GName of Sexton or Person in Charge of Premises �i�,s 5,,tAt
z (please print)
Signature 4t Title `IvY' 3L
(over)
DOH-1555 (9/98)