Wirt, Carrie Vir""
NEW YORK STATE DEPARTMENT OF HEALTH r # 182
Vital Records Section Burial - Transit Permit
Iii Name First Middle Last ' Sex
iti C uC(i e_ eve-rli W;(* I-
Date of Death I Age I If Veteran of U.S.Armed Forces,
iiifilg 03) o71 I ao119 I y. j War or Dates
P. ce of Death /� �� �Q I Hospital, Institution or
CI Town or Village `j � 0�S Street Address 1 Lo C `(\a A l \
-
j Manner of Death L. f i Natural Cause ❑Accident 0 Homicide ❑Suicide Undetermined Pending
1j Circumstances Investigation
21 Medical Certifier Name Title
ti IN • Eala3u b rG rnail f ni
Address ,Z h SjS
Z.r S�-e'e8 : r card i
th Certificate Filed f District Number Register c�r I?Z Cit own or Village Gies " FA1i\g I ,5-66 1 ["
I Date I Cemetery or Crematory
❑Burial I 03 ) O C\ l a.01 u ! T; r\e V i c.v..) Cr e,moa
>:. r I Address
: `�4 Cremation) C OC-e' S'10k->r\J i NI l 25309 ._ - _
I Date Piabe Removed
g❑Removal 1 and/or Held
a- and/or I Address
Hold
3 Date _ Point of
al 0 Transportation , i Shipment
5 by Common Destination .
Carrier
:::-: Disinterment Date ' Cemetery Address
! f
0 Reinterment Date Cemetery Address
Permit Issued to _ ! I Registration Number
__ Name of Funeral Home_ ,_.- . L.'-/'�.:_ ?'.'1:-i,:::� " I, ;Y!!' 1 C i 3O
: - Address f� r�
�t Ij- P//LT iZ f t j 06 `rLS fs i✓l t c1 :U - /2 `I .
Name of Funeral Firm Making Disposition or to Whom ' j
ig Remains are Shipped. If Other than Above `
sg Address -
ti
Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued 3t ct l 1 6 Registrar of Vital Statistics l./1/41 �,•-)--^-"<
I (signature)
District Number 5.6 o ! Place 6 ( t r � \\S , i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
5 Date of Disposition 3//0//6 Place of Disposition -go o,✓ ��n„siforkv,
2 (address)
tll
C (section) lot number) (grave number)
0 Name of Sexton or Person-in Charge of Premises tb)f J tm NI-
(please print)
Signature Title Odantiffla
- (over)
DOH-1555 (9/98)