Kingsley, Harriet NEW YORK STATE DEPARTMENT OF HEALTH It >>7
Vital Records Section Burial - Transit Permit
Name First Middle /_ Last Sex
dt%
Date of Death Age If Veteran of U,,, . Armed'Forces,
_ //--e.?p�� �3 War or Dates �/,�1"
1-- Place of Death Hospital, Institution or
U City ow r Village ] 1,,ree,,14 ei11 Street Address tI -y yvto v tit/4/5 J� /cC/
p Manner of DeathJ Natural Cause ❑tic dent ❑Homicide El Suicide ❑Undetermined ' "ending
W _ Circumstances Investigation
W Medical Certifier Name � Title
CI 4_ /// AID
Ad ress
9c? S C1 _ /�/ /aet��tr
Death Certificate Filed District Number Register Num er
City ow r Village 0kee i. ILA ; S� qt 1 Ia`
❑Burial Date jj I Cemetery or Crematory
❑Entombment /�- E f" /`l 1 me v'a': I/ e1-1t .:_
Addres Cj ,�
Cremation ,44_,1_,kei,/ A ee- 54 s /I/ _
Date Place Remo
is r-i❑Removal and/or Held
and/or Address
Hold
Cl) _
O Date Point of
N ❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home G„/nal ker I:1Lnc c(LI k c ram. 0 1130
Address
11 a .ycfle- S . , &u..censbu.(v , tie „`: yu1" k 12siC --1
Name of Funeral Firm Making Disposition or to Whom
;H Remains are Shipped, If Other than Above _
2 Address
C
ILI
111' Permission is hereby granted to dispose of the human rem ins described' � d above s indicated.
Date Issued f$. /J-1/2iiIl Registrar of Vital Statistics ` 1)k_'�F/�"
(signature
District Number qo c-) Place ((___Lus_sLA„, .
��
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z eni
Ute,jC fofwU_#tl Date of Disposition Nod Zj,qp�` Place of Disposition
2 (address)
(/)
CC (section) (lo number) (grave number)
p Name of Sexton or Perso in Charge of remises
Z ( le_ r
(�St ase r'print) St M�1T
W Signature Title CQG M O
(over)
DOH-1555 (02/2004)