Fertel, Loretta t
NEW YORK STATE DEPARTMENT OF HEA 41 qp
Vital Records Section , , , Burial - Transit Permit
Narr,e First '(� ";n=d,�ile� �I Last Sex
Dr�1 a.
Date of eats}, Age If Veteran of U.S.Aped Forces,
2.`'( 7 q
War or Dates N p
_ 1
1 Place of eath � Hospital, Institution or
City(j ow=i•pr Village ra )� Street Address
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Manner of Death W Natural Cause ❑Accident 0 Homicide El Suicide D Undetermined El Pending
111
10 Circumstances Investigation
tit Medical Certifier Name Title
44 1ko t' an ►ap ) sv' MI)
P.r Ayr nor
Death ificate Filed District Number Register Nu ber
f City,�r Village L J�e lJizerry t L '(p5(p CD
>i"❑BUflal Date !f�� metery qr Cre`at�y
i Entombment � LZO' ti,�e_V le t) tiJli y�J
Addre iJs 1
[ Cremation L(CC-K3bu n M�
Date ) Place Re oved
Removal and/or Held
Poi and/or Address
i=" Hold
iiii Date Point of
to 0 Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homey- Lo f,r 1(1Q,r7-1, ` pnLi I rc„ Co 2_1 '
Address
A-f C 1u_rch JtLcui ., (U.1 u-ne_. izgeffr,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
itt
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1 Permission is hereby granted to dispose of the human r ns ,esc d ab s indicated.
Date Issued (.0 I,3O go(7 Registrar of Vital Statistics �
(signature)
District Number nb Place` n Ot-C 1-00/e. 'JkZ-e-t-
;`_> I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lil ? �
Date of Disposition � 1��'1 1� Place of Disposition �� Catan,..,,
(address)
w
cc (section) �i lot number) e (grave number)
Name of Sexton or Person in Charge of Premises (4!'s LC �J r"~�11
/I (plise print)
44 Signature �� �`'t Title CAT►
(over)
DOH-1555 (02/2004)