Ocker, Christa A . g01
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name ri,rst 1,5_ 6 Middle d c Ke g t Sep
Date of Death Age If Veteran of U.S. Armed Forces,
!// .5 /Z 046 �� �,
War or Dates
14.,. Place of Death Hospital, Institution or,„
Z City, Town or Village S c 4 I-OC4) Street Address "! I / /j , jl�t hetucia, r/ I
ILI
Manner of Death Natural Cause ElAccident 0 Homicide El Suicide 0 Undetermined n Pending
iLl Circumstances Investigation
tij Medical Certifier Na Title
Q i./ i 6 a1 c4ilq,11 4,. ft"1�.1
-::::- 1 26 // Mili/u . 7.". /Ai A i-re to 5 4 oil Ky.. /0-S',CS3
Death Certificate Filed / District Nber Register Number
City, Town or Village C`( 1-67K - 1 (32 6
OBurial Date Cem y,or Crematory ...
❑Entombment �/^ r /N2 t/j;Cl(,I ej-'Q/rkl'a ,G -,
Address
Cremation a
Oe_e ko JV� 1\ , ,
Date Place Refnoved
G7. ❑Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
th ['Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �// -. Registration Number
Name of Funeral Home Ole Ak-k- I, i
, -S holii.14414 f 14//! 0— 005-
Address i j (�
am, kio N)c 12-f-7d
<: Name of Funera Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
#»
to
fl' Permission is he eby g anted to dispose of the human re ins described above as indicated.
Date Issued ,/t/ 0 Q /‘ Registrar of Vital Statistics Z. 2zrc c5 (/LL=L__02
(signature)
District Number 3 Place 51• 4 (TgyL N. w
.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
laf .Date of Disposition pi/lob Place of Disposition ,�,U k ,,, , C on..,
W (address)
U)
CC (section) id (lot number) (grave number)
pName of Sexton or Person in Charge of P emises aI".S r JtiittP
zr 9 (pl ase print)
W Signature �� Title G mitiG
(over)
DOH-1555 (02/2004)