Kilcullen, Nadine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section h ,` Burial - Transit Permit
Name F rs M/iplle st Sex _
Date of Death Agef,i9 If Veteran of U.S. Armed Forces,
l/` 7 War or Dates /70
fg.
,:i_l of Death Hospital, Institution or /�
�// Street Address c7fs'/ ?fc j i
Manner of Death Di Natural Cause Accident Ei Homicide El Suicide riUndetermined El Pending
t: Circumstances Investigation
la Medical Certifier Name Title
/472OW/ U,e/hy e,,egy2
Address L3-? /7 i7,z /G'l J /*/ /C-/ivEry
Certificate Filed /,, District Number Register Number
Mi City own or Village ��e/7s �'7/J J W(Ji S�-
Burial Date Cemetery or Crematory
at/e ide.// r/z i7G iJ C4eme&XI,/,'?
['Entombment Address
Cremation c've 2sJ2z J/1 /',(" t /� 4/
Date Place Removed
Removal and/or Held
and/or Address
F.:: Hold
0 Date Point of
Os E Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to- Registration/N ber
Name of Funeral Home G.` �, — Voce e17 P / Qe/1/
Address A(/ --- -C) - (.9"lf'S'e77-er '1 l 0(7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
2 Address
CC
fa
Permission is hereb granted to dispose of the human remains des ibed abov s' . ted.
Date Issued w2 � Registrar of Vital Statistics �,�4,' L,'t- �
(signature)
giiii District Number.3 7/ Place 4/e4s ,/L /Cl/ /21-,j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition DEC 1‘ Zqt Place of Disposition Pm Vt,,,) CNn,4ti(wN
(address)
LEI
til
CC (section) /r . (lot number) (grave number)
G! Name of Sexton or Person in Char a of Premises r' fL e- e'+r4tt
AL
(please print)
14 Signature Title CQi mfccO&
(over)
DOH-1555 (02/2004)