Rist, Vera NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Narpq First Middle Last Sex
1st
Date of Death Age ITVeteran of U.S. Armed Forces,
—7 —5-ZD (l.o 9 t War or Dates >Nfo
1-- Place Death Hospital, Institution or
Z City own r Village aj uec nsh Street Address 11 C Manor U r.
l Manner of Death E Natural Cause ❑Acdent ❑Homicide ❑Suicide ❑Undetermined ❑Pending
1411 Circumstances Investigation
W Medical Certifier,_,� Nam(me CC 1 Title
�dd ss -6 0 l ` M
-e-+—
r
Death rtificate File riot Number Register Number
City, "Qow4or Village Uce....115b(,_r? (,gs n
::. ❑Burial Date Ce etery or Crematory
��
['Entombment -7 _g —'co I)ne \f ieu� .rt-1nLl!v5
Address
;'Cremation SIA-12-trISIOLI,
Date J Pf Ia6e Removed
Z ❑Removal and/or Held
2 and/or Address
I= Hold
0 Date Point of
Transportation Shipment
25 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 'Bre,t0e - .k A v1P,rix' nyl.Q_ ' r)L 04-1 I
Address c9- _^ U,CCP\ S t La- L 1.21-/- NY )2*
.
Name of Funeral Firm MakingDisposition or to Whom t¢¢-�
Remains are Shipped, If Other than Above
2 Address
t
LE
P` Permission is hereby granted to dispose of the human r mains described a e as indicated.
Date Issued I gl l Registrar of Vital Statistics q. 't--__-
__
(signature)
li District Numbe!< P"') Place ( b c \ d4 l r
I certify that the remains of the decedent identified above were disposed of in accor nce with this permit on:
ILI Date of Disposition 7 I ii hi, Place of Disposition ?At V, /
2 (address)
1a
CA
CC (section) (lot numb�`) (grave number)
0
fa Name of Sexton or Person in Charge of Premises , N.; J l^N�
z (please print)
Signature ✓� Title fYIiEN
(over)
DOH-1555 (02/2004)