Ritson, Rosemarie NEWYORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - llran7lii Permit
I Name first Middle Last Sex
�OSG'no- e � - ii`i rsc 4 �A/..
Date of Death Age If Veteran of U.S. Armed Forces,
Oil /6 - -,p/6 �S� War or Dates /v a
1•4 Place of Death Hospital, Institution or
5 City, Town or Village wv c�..e✓o �.. Street Address a5c_s L.0&iA 77;ii) 5 FTe
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Manner of Deathatural Cause 0 Accident Homicide u Suicide Undetermined Pending
W. Circumstances Investigation
la Medical Certifier Nam Title
0 GIek. (I A 'niw1 o P7d _
Address
Death Certificate Filed ` DistrictNumber Register Number
City, Town or Village WC-0 kJ a e.--cc c` /.-Sm�6 t
OBurial Date Ce�ery or Crematory
❑Entombment Li— fl8" /� U/kie- b/eji9 eI-Qri1A1ae
Address �/
cremation d 2;e NS 6 vvr N,_�i! 4 /a
Date Place Removed
Z ❑Removal and/or Held
and/or Address
M= Hold
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0 Date Point of
Q Transportation Shipment
t
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
mEi
Reinterment Date Cemetery Address
Permit Issued to /f Registration Number
Name of Funeral Home ES(.0A L. k ! Utterh( (j'l 0185-I y
Address Cm i
eh 1—e- )-- ,4 / N Q / g C'7�
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
L
A. Permission is hereby granted to dispose of the human remai escribed a ove as i t -cated.
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Date Issued ® jgf��E/6 Registrar of Vital Statistics -\ . , , ,,,,,`J CIS'\
(signatur t
1111 District Number `4 Place G /k
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
q�/ /i Place of Disposition ZUL., e,.r-v�
lt� Date of Disposition �� p r'
a (address)
U)
CC (section) t (kit-number) (grave number)
Name of Sexton or Person in Charge of Premises rtt S "
Z (�ase print)
Signature a 1---' Title ttn-
(over)
DOH-1555 (02/2004)