Hollenbeck, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH ' ill
D D
Vital Records Section Burial - Transit Permit
Name First " 'r �middle �� / Se
!�z A 6.� fit 6GT� � � ,b
Date of Death Age If Veteran of U.S. Armed Forces
II 0 t 9 - 4 // g War or Dates Aia
P4 Place of ath Hospital, Institution or
City, own Village I r coN�e r-o 9 A Street Address /0/? W, cKc . j,-.0. . —
Manner of-Death tural Cause 0 Accident 0 Homicide n Suicide O Undetermined ri Pending
lit Circumstances Investigation
W Medical Certifier I gi Title
a r a�j_ Ul41 f. 'r MI)
Address
IP
/0/ i 4it�c--4/- £T• LITCSucier0i>t Ny-. 2_ Sr8-3 ._
Death to Filed District District Number Register tuber
Niil City, Town illage / iCE1JdQr Cl A /.s 6'/ d
❑Burial Date C etery or Crematory
❑Entombment a - /f` rN2 v/Q ic, (D y,o....-.i ed 17-7.•
Address
EGremation U/c)e e.tis.b 0 kr AJ y
Date Place Removed
Z Removal and/or Held
2❑and/or
Address
Hold
fiI
0, Date Point of
CL al Q Transportation Shipment
. by Common Destination
Carrier
ft
Q Disinterment Date Cemetery Address
t i Date Cemetery Address
'''Q Reinterment
•
Permit Issued to Registration Number
Mi �,
Name of Funeral Home t d,,,,p _, J ,.4://, Ft,,pie 61 I IIow-e - 0 cs a-D
iiiii
Address
Ni
efi--,,,, t,,4_ x),,e, , I g-t -26
<' Name of Funera Firm Making Disposition or to Whom
fi Remains are Shipped, If Other than Above
• Address
cc
to
fl" Permission is hereby gr nted to dispose of the human remains scribed ve a . dicated.
pii
Date Issued - dZ 02 Q//Registrar of Vital Statistics /it r�
c ( i ature)
District Number /jg,. / Place / N iPi-o r
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z (�
ta Date of Disposition FEgiyr ZOO Place of Disposition PruO,ct, C!'(A.ctoc«
W (address)
t/7
CC (section) t , [[ (lot numbe (grave number)
(i
Ci Name of Sexton or Person in Charge of Pr mises ��S�i,"A�`if Jt h«fr
Z (please print)
tit SignatureIri Title Gr2 /h 19'Ja
(over)
DOH-1555 (02/2004)