Harrington, Alice NEW YORK STATE DEPARTMENT OF HEALTI- ' P I tiq
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ALICE T.LE EN ft Ri2 tN6-TO`J i=
Date of Death i i Age If Veteran of U.S. Armed Forces,
03 ill ..0 I I $9 War or Dates
1-.. Place of Death Hospital, Institution or
City, Town or Village Street Address
ILIa Manner of Death ®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
o S AN t- , Kim t.l.I DO
Address
1i NORT1-r 3T. GRA1'J iU.t: N 1 I)43,�
Deat ificate Filed �^ District Number Register Number
City, Tow or Village is R J V(LIZ 5 7 S 6 (®
❑Burial Date Cemetery or Crematory
6311 doto1 i 9INCVIWIJ Cge-v V12R`I
['Entombment Address
:: roremation rj`(JE�T156u(Z.Y , N 1 1a8'o
Date Place Removed
1g ❑Removal and/or Held
and/or
Address
Mr In
O Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home T1kyN4(2p..p,,poK,-e. Ft) JtirPtit. Ito r31f e, 1141
Address
Ii i—AFAy - T6 sr Qu Th1SPa&RY I n%\I I pgo4
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above .
• Address
#1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03 Registrar of Vital Statistics \
�I �la�1l g� ���u� �
(sign ture)
District Number 5'7 sl. Place -rowf\,i O F NVit,.1
jI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �'
la Date of Disposition 3-ZI_t 1 Place of Disposition ?Nu CA" avvicfol'ivv1/4
2 (address)
ill
W.
CC (section) :lot nu r) (grave number)
Name of Sexton or Person in Char f Premises (11::
s Jp,,,,
z (please print)
41 Signature C ' L Title City-vh 'Oe.
(over)
DOH-1555 (02/2004)