Salvador, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH 4/ 113
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'_ �ma-�-\ )eey A : fe Scl NICKdaNr-
Date of Death i . Age If Veteran of .S.Armed Forces,
Q Z t Z I ' $ War or Dates N )f)r
Place of Death Hospital,institution or
City(1 owwor Village oV ee rSbt34r�� Street Address 'S
r' OC'C\1 Or i' -0,,(S\r ai'll e.
W.
,rriManner of Death ► 1 Natural Cause Accident Homicide Suicide ri Undetermined nding
Circumstances Investigation
1. Medical Certifier Name Title
SUZUY, `�Doh
Address S Nr o n A e ; &-k o,,s G—O,\\s ; r, \ \R O 4.
Death Certificate Filed District ber Register Number
City ;er Village �eey\60Uvf. 1 � 1
QBurial Date Cemetery or Cratory
❑Entombment 6 .I 1 a ) a o 1 v) P;\n>= \c.03 C) e.rrl a ,r`t
Address
:: Cremation Q OccC\C12v- R_s (1Vee_{\.S\J Y AJ
Date Place Removed
Removal and/or Held
and/or Address
Hold
VI
Date —Point at
rL�-�ti Transportation Shipment
ro by Common Destination
iiii Carrier
' Disinterment' Date Cemetery Address
:
0 Reinterment irii
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Ulna(et .€aer Futter csi 01 I 30
`=_= Address � v.-i U{" k2 S'U L\
1 {ltfi� � C ��. , QLICSbU,t� , (
`` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tik
Permission is hereby granted to dispose of the human remains described above as,ndicated.
a Date IssueaD4 I J--1001 k-,,Registrar of Vital Statistics 0 ,2 __
(signature)
>` District Number. Place '
C • • '_ .._.,__-..il
'. I certify that the remains of the decedent identified above were disposed of in acc-'dance with is permit on:
la Date of Disposition 2111111. Place of Disposition f iq.Olt✓ to'
2 - (address)
gt
(section) iiii� ( i number)v (grave number)
Ut
zi Name of Sexton or Person in Charge f Premises ris *ease prtnt) Vine"
iZe
Signature Title NIt rl7L
(over)
DOH-1555 (02/2004)