Kaplan, Margaret t f
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Parccc e -t- Ka trail Female_
Date of Deat A II Veteran of U.S. Armed Forces,
( —z - ) ' War or Dates kip
{-• Place of Death f Hospital, Institutio or .,n
• flan, Town or Village C`n5 et r Is Street Address I !n e5
er of Death Wm Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
til Medical CertifierName Title
fthrwill -Frzt AA
Address
v le-n 5 i--Cl its
Death Certificate Filed i District Number Register Number
ity, Town or Village bie415 7l Us 560 / 3
❑Burial Date `` etery or Crematory
❑Entombment ( _3 1 7 r r C V!n‹ e 40 nwf D 7
Address
,Cremation Guar)sbiLru (VJ
Date Place Removed
Z Removal and/or Held
42❑and/or Address
i= Hold
ID
0 Date Point of
co)❑Transportation Shipment
C! by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
lin Permit Issued to Registration Number
Name of Funeral Home Br..e r 4V1Q,t I -41-ornelI h C 064-/0
Address 11- O jil iA-.!r,irl St ak f.. at ip,A k /bodk,
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
• Address
t:LI
P.' Permission is hereby granted to dispose of the human remains described above as indicated.
ii Date Issued i l 3/ 20 t-] Registrar of Vital Statistics r IN
(signature
District Number S b Q i Place 6 _s TU k\S kT y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition (-4`(1 Place of Disposition rl/MAw/ `141' ----
2 (address)
ILI
{l
CC (section) lot number)C, (grave number)
aName of Sexton or Person in Charge of remises artr �a,+�i�
(phase print)
iii
Signature Ll a/ Title C M�
(over)
DOH-1555 (02/2004)