Freiberger, Martha 14 LA
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First /i vz y� Middle LEiei
t / S'S x o e r a.
Date of Death Age If Veteran of U.S. Armed Force
/ 9/ // ?a War or Dates /70
Place of Death/ / / Hospital, Institution r /� Pic
Z City, Town o village 4r na ll � Street Address Q/t L,tier 1� '/c�-
0 Manner of Dea ® Undetermined Pending
�� Natural Cause �Accident �Homicide �Suicide � �
iii Circumstances Investigation
tu Medical Certifier Nam 9, , Title
44 *./9/74/, r )ta,Vs 121. 4
Address
/7 r`.�-A. �' '
Death Certificate 'ed District Number Register Number
City, Town illage 6r //,//e 5 4P4.1 .3 7
❑Burial ate f Ce etery Crem ory t/
['Entombment
���` pne � cre hr/
Address:::' Cremation 62ue,e4u6c ry
Date Place R6moved
IS ri Removal and/or Held
and/or
Address�
St-
Hold
0 Date Point of
D" 0 Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to p Registration Number
Name of Funeral Home ma y/yer&TI , 1 br 0 //.30
Address
11 f (F �k aae&tsburvAil 1Name of Funeral Firm 1Vaking Disposition or to'Whom
} Remains are Shipped, If Other than Above
2 Address
a
lU
Permission is hereby granted to dispose of the human rem
'ns describ boy s indicated.
Date Issued / /9// Registrar of Vital Statistics
(signature)
District Number 57a 5 Place Grail//>//per Ay /2 e a--
:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t� Date of Disposition DeC 101Nit Place of Disposition 'FAIL) CffirotbflW.
(address)
It
U)
CC (section) 4 x (ot number) (grave number)
it
Ci Name of Sexton or Pe on in Char of Premises / h 1 Sevort
please print)
C¢1�2M 1
Signature Title tilt,
(over)
1555 (02/2004)