Weissinger, Beatrice NEW YORK STATE DEPARTMENT OF HEALTH
617( '
Vital Records Section Burial - Transit Permit
iiii Name Firs Middle Last Sex
V 1607nj er F be'ari-rfc-e
Date of Death Age o I- IfVeteran of U.S. Armed Forces, �/�
LQ J c3o I Li / 2• War or Dates
Place of Death /� Hospital, Institution or G')ens rail( Harp,-1-+�.(
ri Town or Village (f -ear /q,j/J Street Address /Up Park ex Glen, A_((r,NY.Manner of Death N Natural Cause ❑Accident El Homicide 11 Suicide Undetermined fl Pending
Circumstances Investigation
11.1 Medical Certifier Name Title
G1 G cArna1 1I\het 1: VI 1,
Address
to Po4.rA. S}-rem} , GLEN%S FA\%S, Ny t'LSO I
Death Certificate Filed District Number S�a/ Register N�{
; '.Cit own or Village G1 e,rS �q�1$ I 6J
1 Date Cemetery or Crematory ,--?
❑Burial 01 •04.20110 hoc View Crearrdent
Address �/
c0Cremation CO (,(p. ( ! eau ew_/is h&��/ !"� )- /- /2 Vd y
Date I Place Removed /
3 ❑Removal j and/or Held
r2 and/or Address
Hold
0 Date I Point of
fiki 0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
E Reinterment Date Cemetery Address
<i Permit Issued to Registration Number
I Name of Funeral Home _ p --r t f-�,,4,-NAB , ,y 01130
<`I Address 1
iiiiq 1/ Li)-. vTiz:� i. u ,. ,,,as a u r? r /2. i/.
€> Name of Funeral Fi Making Disposition or to Whom f i -
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains describ dab ye incl. t .
iiiii Date Issued 770//Zvl'6 Registrar of Vital Statistics �
C,
' „ (signature)<' District Number 66O/ Place 6-1- do A: //5, AY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f:-
Date of Disposition `) rS'f l l, Place of Disposition flUL.i . 'r-'._
2 (address)
w
Va
CC (section) (lot numbertytt (grave number)
• Name of Sexton or Person in Charge of Premises • nirpL
Z (please print) /
W Signature (Ili `-' ._ Title L 4 TM
(over)
DOH-1555 (9/98)