Fortune, Dorothea NEW YORK STATE DEPARTMENT OF HEALTH Burial ® T�' nsit PermitVital Records Section
Name First Middle Last Sex
., a o h--9 U)v t_A- Fort i u,)ter" Felt t3z IC
`= Date of Deaths I Age I If Veteran of U.S. Armed Forcep,
`' / f 41/2-c)17 1 sn'O 1 War or Dates ,-)
i Place Bath Hospital,Institution or i
2 City, Town r Village 0 O -AJ.s es li
Street Address I L iii A/^) i4d [1'
laManner of Death Natural Cause fl n A - ent Homicide 0 Suicide Undetermined Pending
I Circumstances Investigation
�_q
j Medical Certifier Name Title ,��
rm Lj P Ck�2/- �1,,
Address
a g 72,091) l—i 6.t) cArt rt-40 47 /Z F2�'
Death rtificate Filed I Ds i�umbergiller Number
City,g-ouirDir Village U e r,L a { ' (Q c
' 1❑Burial f Date Cemetery or Cremato
Entombment1 I I 17 I 7 f,-J U 11 b" D
Address
`kremation U ag'/L by‘. U >O S Q 7 . A/
4 Date j Niece Removed
Removal I ( and/or Held
9 and/or ' Address
e
di Hold 1
45 Date Point of
coAL Transportation Shipment
ci by Common I Destination
Carrier i
C Disinterment I Date Cemetery Address
E Reinterment l Date 1 Cemetery Address
'i;:i'i Permit Issued to Registration Number
Name of Funeral Home .C - "-1 >✓; t l �t \ NO I t- C',t t C`
Address
t
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
ill
Permission is hereby granted to dispose of the human rem ins described above es indicated
�
Date Issued J 1 /")! ) Registrar of Vital Statistics C� Qi y L �lJk,y.�
(signature)
District Numbers-toc Place l(,) ( D . v Q(.. _,..�Ch
I certify that the remains of the decedent identified above were disposed of in ac • danc- with this permit on:
Z
i. Date of Disposition I/iq In Place of disposition qty.,' �( atom ...,,
2 (address)
ILI
01
LE (section) / (lot number) (--, (grave number)
nName of Sexton or Person in Charge o Premises 4r;f ase 3t-o.1.�.
(pi print)
to Signature 4 Title a Emett 4'
(over)
DOH-1555 (0212004)