Kline, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH , 0:37
Vital Records Section Burial - Transit Permit
5 Name First \�\ dle Las Sex
�Jd�2.0 1 Ham' c:\ IRS ic(.i Al Li-- Fern Zf9
];: Date of Death / Age If Veteran of U.S. Armed Fo es,
// 1,b 6 ,,�/)*
=::: �1� War or
` Place of Death , H: Spit Institutio
:4 Cr „+Town or Village ' te.�.S /�htZ,t,S l Street Address / ,yam- (€4
anner of Death'1bl Natural Cause El Accident 0 Homicide El Suicide m CircuUndetermstances ined 0 Investigation
119 Medical Certifier Name Title
Address
i is th Certificate Filed District Number Register Nu
ity, own or Village cm Lim /1?(.:s
17
Date `'�
Cemetery Crematory fj ,�
0 Burial ///2-2-1£ r(�e-V/�,�
Address
::> emation Q 06. ti.__ Q v '.�s'i �(
Date Place Removed 7 / "
0❑Removal _ and/or Held
and/or Address
g- Hold
Date Point of
❑Transportation Shipment
ti by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
''•• Permit Issued to Registration Number
• Name of Funeral Home iia;t;,z,N ), Ri4< F..,6 3-_ h,y °jar
,__, Address
I I/ / t) ,6 S;• 0 u as d U ay A /24f'o if
Name of Funeral Fi Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i -
Permission is hereby granted to dispose of the human r ains described a ove as indi ted.
<> Date Issued /i J2;zoi Registrar of Vital Statistics _,� �-C
((( si a re
"'s District Number j / Place - e I/
t
l I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on:
6 Date of Disposition OVA, Place of Disposition I-f GtL--1 c;'w.c4"�
2 (address)
iii
CC (section) /(let numb (grave number)
aName of Sexton or Person in Charge of Premises /1��'p� ..1.4}
Z. (please print) /
41 Signature a .- Title l401117X.
- (over)
DOH-1555 (9/98)