Kingsley, Ruth -. 1117
NEW YORK STATE DEPARTMENT OF HEALTH ' - ' A
Vital Records Section Burial - Transit Permit
ES Name First n f/ Middle Last Sex
No' ' &GLe-..i k t/0c; S L&I: F
=>E, Date of Death A [ ifV ?ranofLLS.ArmedFor ,
ri::» ? q ar or Dates td-
Place Hos ' on or
-: City Village v�1 JSQ Addr .S 6j.,,iiiiiiS-1-I, AOL_)
Manner of Death �: Natural Cause O A ' icicle-O Suicide 0 Uroad :Pending
ifiCitances Investigation
ta
Medical Certifier e Title (,r)
ftN (J/tL,r,7 and-I /l`l )
Address
IR
/4/ A9sAldtc_ K._ Geci Ai/y /2.,ceo y
Death to Filed Number f R ister Number
{" CiiY,�� ��1 Z��r-Aii (/{'t-�" (l� LDS
Si['Burial Date 7 , �/ Cemetery Cremat ,;.")
U
/
=: Ot" mbrrmnt Address //
rCremation C) U 61-1,iS,r1 �� -
Date FIace R ved
ElRemoval and/or Held
and/or
Address
Hold
Date Point of
O Transportation Shipment
by Common Destination
• Mi Carrier
❑Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
id
Permit Issued to Registration Number
:: Name of F:in:ral Home t"i Gy(1(tX l c� k �i ii f(f(Lt {{ )t yam 01 I O
Address
1 a y�+�e S�, , Qi�eensbu,ry , New Y�{� t2�oy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
SI Date Issued.1I ( D ( 011) Registrar of Vital Statistics 4C� Li,, , 'T 1L�
_ O
i'>}' District Numberc� --I Place c)� � „S
oizi
'7
' , I certify that the remains of the decedent identified above disposed of in dar e ' this permit on:
Date of Disposition - 1- I t Place of Disposition Qr c Vow r c for,
oddness
tii
WI
(secion) q R (lotr ) (grave number)
Name of Sexton or P on in of Premises ` t'4 4 ' J e v*.
(please pint)
Signature Title al t; Hl ri-t i(1.,
(over)
DOH-1555 (02/2004)