Kitmacher, Pearl NEW YORK STATE DEPARTMENT OF HEALTH . if elEir
Vital Records Section Burial - Transit Permit
.
Name s year( Middle ixt �� Sex
m adi
Date of Death I Age If Veteran of U.S. Armed Forces,
OL 1 22 120 I if 13 - War or Dates fAD tA3 a-
Place of Death /� Hospital nstitutio or-fir /7° Marren Si
`Z(ity3Town or Village (r/e )S P z I li Street Address ! he Pints 6/ens F4.113 NY.
• 0 Manner of Death EVNatural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined El Pending
III Circumstances Investigation
Medical Certifier Name r i Title ,y
Q l(1(NA), 7H J .0 G(.'/ / l
Address
�Le- r i I t9u,S /I - Pi i fl-L -
i9 ite4ti Certificate Filed District Number Register Number
ity, own or Village Cj j,j.iJS 1r 1 LDS T1 O / 3 2 C)
Date Cemetery r Crematory
❑Burial 1/ 2 )I/ 4 Vj n.e
Address v
::: Cremation o� �u�eflS //i NV. I Z eciti
• Date j Place Removed
. 0❑Removal and/or Held
-• and/or Address
l* Hold
i
Q Date I Point of
0.10 Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to -� � J// Registration Number
Mil Name of Funeral Home '.�MKi12_ !"�:� �'t .. /7 N 0039
3O
' Address
/1 C I t- S . G 06�.os IS O,� , i y
Name of Funeral Fm Making Disposition or to Whom (� 1
Remains are Shipped, If Other than Above
`J
Address
cc
Lti
{
=r Permission is-hereby granted to dispose of the human remains described above as indicated.
`'<:' Date Issued b(Z3 l J6 Registrar of Vital Statistics WC'_.4'1,\.t INL.^
(signature)
District Number 5 6-0 i Place 6 CQM S. 'CA `\5 � /a y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4,1110 Place of Disposition gio,,.- �,�w f&-
2 (address)
ILI
VI
CC (section) hiot numbe (grave number) •
AName of Sexton or Person in Charge of Premises 4.irn-
z
(please print) '`
44 Signature a Title Cg-Altk
•
- (over)
DOH-1555 (9/98)