Partenheimer, Lorraine 1i '/t1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
L_or r cl.c.�Q , L e-hc i cam. Par tense
Date of Death .Z Z g ti_9 Age . If Veteran of U.S. Armed Forces,
—
li -iLI) War or Dates
Place of Death osp}t ?
., I _ - :._ C lel s c k.^^e
C ls�-v -o.11l3 USP i- al
i
Manner of Death Natural Cause ❑Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
• Medical Certifier Name Title
a
eeca N\o6ss N\Th
Address
3 V rC)ryn Ve C n;rer Gu c>s o� N\ i 2-8a 1
<€ Death Certificate Filed District Number Register Number
iiir5 e� Ll 3 Tam Sr6or/ /0 7
El Burial Date NIA 1 L9 > etery‹n;remato p i�u JJ
Address � �1 1 /
emation /( L, .tis 120-1
Date ( Place Removed
0❑Removal I and/or Held
and/or Address
}= Hold
0
Q Date Point of
Q Transportation • Shipment
ES by Common Destination .
Carrier
Disinterment Date Cemetery Address
I I Reinterment j Date Cemetery Address
iiii Permit Issued to ( At
Registration Number
<= Name of Funeral Home _ Rt-r611 J�,-, r1.,3 r_, )�L�yt- 01139
Address .,
it Ll.)-� CTTh .� u Ns c, °i �l . /2..--c3 `t,
>s? Name of Funeral F Making Disposition or to Whom r 1 -
h Remains are Shipped, If Other than Above
IAddress -
Permission is hereby granted to dispose of the human rer wins des ' ed above`as innddic• ed.
Date Issued O Registrar of Vital Statistics Gl -1 1224. 47
(signat e) y�
II District Number �6Q l Place 4 ., � / /
I certify that the remains of the decedent identified above were dis sed of in accords ce with this permit on:
W Date of Disposition 314DJl, Place of Disposition a� �rwr+ b{jt� w.
2 (address) ,
iLl
U)
It (section) (lot number. (grave number)
GName of Sexton or Person-in Charg of Premises • A a to e N -
z (please print)
W aSignature 11 Title 1174 lift
- (over)
DOH-1555 (9/98)