Kahn, Doris I
t • , NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First'; Middle _ L s Sex
4Y)rt 5 1 � VI 4 _ �A n F
Date of Death Age/ If Veteran of U.S. A med Forces,
/21 g1lo2a/ 0 cR War or Dates
lr Place o -�-ath Hospital, Institution or `v 5/*
� C L� Ed
W City ow• or Village (j/y � /
t _, Street Address V"5?/
a Manner of Death tXfNatural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined �Pending
W Circumstances Investigation
tu Medical Certifier Name Title ,
cScwit f'lu'.kAi // g it ff/A yScea-yL,
Address
3 5rK-1 y o $ n.t,04 !36/?
Death C 4 icate Filed District Numb Regiisjter Number
City ow r Village � l.� a-y5 2 / �6l/lo
'.►�Burial I Date Cem em y or Cratory
v f/0 Vd-d/ ? VI n.e U r..-.cc e r t
❑Entombment Address
[]Cremation l!d 115
5 Place Removed
❑Removal and/or Held
and/or Address
F Hold
tft
Q Date Point of
❑Transportation Shipment
p by Common Destination
Carrier
Q Disinterment Date ' Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to � � � � ///��.. Registration Number
er
Name of Funeral Home t 2q4 £e y1 /Lt t ! fL 77
Address
q4/ 54 r41 4 4-W w�Lt SQ &,n 5 67/5 N/ 4 Eras
Name of Funeral Firm Making Disposition or ha Whom
1- Remains are Shipped, If Other than Above
2 Address
CC
I L!
Permission is hereby granted to dispose of the human remains scribed above as indicated.
Date Issued /g/a9A({ Registrar of Vital Statistics _ %c
c (si ature)
District Number /52 �//I
Place 6 �U
1
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
Z
Ul Date of Disposition 1 /7/201 7 Place of Disposition Pine View Cemetery, Queensbury,, NY
2 (address)
W S.I. 2 134 1
CC (section) (lot number) (grave number)
to Name of Se ton or Person in Charge of Premises Connie L. Goedert
(please print)
Signature
L° Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)