Kilmartin, Barbara NEW YORK STATE DEPARTMENT OF HEALTH $fib
Vited Records Section Burial - Transit Permit
i
.. Name First Middle 7 Last Se
sf
• Date of Death ` ir1 Age 1 If Veteran of U.S.Armed Forces,
1\\0 1 0ku l07 no
War or Dates
• Place of Death Hospital, Institution or
4 City,Town or Village 6._ u,-e..--ED4xtict. Street Address 2 3 C-e( .(Y\l GiL2 (oor~ Manner of Death a Natural Case ❑Accweg p Homicide ❑suicide ❑Undetermined Pending
Circumstances Investigation
'Y Medical Certifier Name �"� _fl S1kSQn e0o Title 11 -A.P.
Address
Filed j Dis C.9
r Register Number b
v City,Town or Village (,t -r - ,
❑Burial Date r Crematory
'1 [d� 'C!1 J Ceme fl-e VD CA.12-Nleti N
Andress
CremationPRoacjc 1 1, 1
Date Place Removed
g❑Removal and/or Held
.r; and/or Address —
g Hold
Date J Point of
[�Transportation _ 1 Shipment
a by Common Destination
Carrier
::.Q Disinterment Date Cemetery Address
E:3 Renterment Date Cemetery Address
„ Permit Issued to Registration Number
Name of Funeral Home Ha/nand b. 'Ctker Fr.wet-al home.. Ql 1 30
Address
I Lafa.ye#c a+. , C u sbu-r-/ , Ai w York l a'Cy
�i
J.
1 M1!)
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
t
Permission is h granted to dispose of the human rem ins described above as indicated.
Date Issued t l ha(C Registrar of Vital Statistics �_ q, a( .,„.�i
‘, .
(signature)
�A District Numb (9 C -) Place ) O t-�-, CS- (;)e.,,.,(, -,,.s6
£
I certify that the remains of the decedent identified above were disposed of in .« • «- with this permit on:
fn
a Date of Disposition )1)1511b Place of Disposition5. eUk ' e�Ol0«..
(address)
gr
(section) / (lot number (grave number)
,G Name of Sexton or Person in Charge of Premises ihittpir J+a l b I
2 (please print)
> I Signature 'I Title (IZ€Mgt
4 .
(over)
DOH-1555 (9/98)