Kleenan, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section unall a Transit Permit
>' Name First Middle i> Last Se
- z Date of Death i .�/ I Age If Veteran of U.S.Armed Forc�
S i/ ) , &) I War or:_,..o) tp /v
i''` e of Death i Hospit ( stitu _-
:
own or Village T L�" , Feu. f 1 Street Adress ) 1 l^i VIS
4ei * anner of Death JNatural Cause ❑Accident fl Homicide El Suicide 0 Undetermined 1-1 Pending
W Circumstances Investigation
iri Medical Certifier Name J/ Title
(SS 'h�1.bv& )\-0)
:._:::.:.
Address
-_, -/- e evt, h-/6 Ct,)6M-7..4. 13 kiY1;i
th Certificate Filed ��'''' strict Number Regis r N be /
Ci Town or Village (,or'„i- 1 i-L j . 4
:❑Burial Date Cemetery o Cremator_y_)
16
i pubs- kei.,..)
E"bmbrnent Address 0 Ay
_ remation �j C bw VK t1b`�iv�IS L
,, Date Place Removed /'
t — Removal ; and{or Held
- —and/or
Address
Hold
0 ' Date Point of
Transportation I Shipment
by Common 1 Destination
Carrier 1i
Q Disinterment I Date Cemetery Address
=> ❑Reinterment 1 Date Cemetery Address
>< Permit Issued to 1t Registration Number
Name of Funeral Home .�jE_ �...\e.iZ \ Ho-c) 4 (-11 ;
Address �,.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z. Address .Liil
Permission is hereby ranted to dispose of the human re ains des ribed aba a as Indic
Date issued ft/� /�Registrar of Vital Statistics
/ (signature)
District Number / Place
I certify that the remains of the decedent identified above were isposed of in accordan with this permit on:
E
lli Date of Disposition y,S I 1 ill Place of Disposition ,;.t1;,.,, L 'io^
tt (address)
l
ra
(section) 1, (lot number) (grave number)
0.
Name of Sexton or Person in Charge of Premises l:;r. S'',,It-`
lease print)
Signature ! 4/- Title C " 24
(over)
DOH-1555 (02/2004)