Hill, Katherine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�4 T1-tFP..iiv /ti.r 14/ -
Date of peath Age If Veteran of U.S. Armed Forces,
0 5/2 42/7 !�7 War or Dates
} Place of Death Hospital, Institution„or
Z4• 41P Town or Village 6,4 l4-- - t'gi'ptc,S Street Address 41Z'C 4 '*SF'(154E
1 anner of Death Q1Jatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
IL/ Circumstances Investigation
• Medical Certifier Name Title
Address
5A c Spzpv`,5's AI (-/
D th Certificate Filed District Number Register Number
own or Village S4R4 r ,c i 5f 'i t5 :
El Burial Date �+ Cemetery or Crematory
❑Entombment 9 '/.3//27r/ Pr,v.� Vial c /14--'70` '7
Address
l6 N
emation 62 5 n., i v_ ®
Date Place Removed
Z Removal and/or Held
2❑and/or Address
F- Hold
LI)
0 Date Point of
ftEl Transportation Shipment
O by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home gqrW;� > c- E.,— A-k7/-1, /./ve.. Q02 15
Address _
2c cid -7/ sr- -�'z--) & j 4,1k4. 1-i2. . i J /uy /
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above .
2 Address
cc
w
I L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0,5/ i/ Registrar of Vital Statistics
s na ure)
iir District Number Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
1a Date of Disposition (,- ►-t\ Place of Disposition Pv d'UL) 1 i :f'\w,,
2 (address)
iii
to
jr (section) of number) (grave number)
ftl Name of Sexton or Person in Charge o Premises G h(4 r —fit legit
(please print)
Signature 4'L Title CQ. RT6 ..
(over)
DOH-1555 (02/2004)