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Harrington, Helen t NEW YORK STATE DEPARTMENT OF HEALTH i r Vital Records Section Burial - Tra sit Permit -^ Name First ,le i � � Middle , j Last y tarn IN�n ` Sev til::>:: Date of Death/J�� qqe ' If Veteran of U.S. Arme orces/ {.` '7 j W- or Dates /U P ce of Dea / � /'/f� ospitalylnstitution or 01.02 �� Ilk-J O N.Y. City, wn or Village 4l if /'C�.l,6 -Street Address /_ /2,41 y7iin : Manner of Death t--� �� P�C�`� �� pNatural Cause E Accident ❑Homicide u Suicide Q Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title 7. `.2(1111 � �. b 0�t10 lg..n. D Ad ess l Part- ko-e4 Gas I o Iii th Certificate Filed �^ I District Number ( ! Register Number City, own or Village L�,� Fine_ SLV�� I. 1 ' Date /y' Ce etery or Crematory ❑Burial as I w ` {(.v I Address Ldti Cremation Date - ; Place Removed " ❑and/or al I and/or Held ' I Address HoldtO . 4 Date Point of Q Transportation,I ; Shipment fl by Common Destination . Carrier :: Disinterment Date Cemetery Address ! t n Reinterment Date (' Cemetery Address .-. lig Permit Issued to _ . Registration Number Name of Funeral Home - !.).40v1_ .' v.,Jz5}.>}c_ M=Yc- O/j 3Q Address ` Name of Funeral F Making Disposition or to Whom clay � ' . Remains are Shipped, If Other than Above ` 14 Address Ix Permission is hereby granted to dispose of the huma remains d- -cribed a• •ve as ind'cated Date Issued dea aolrwlp Registrar of Vital S atistics 4 :' . Alf A_ ' (Si . ure) ,�© Place �/� c/ 7 District Number ,� I certify that the remains of the decedent identified above we - disposed of in accordan e with this permit on: 5 Date of Disposition6-ZI-/6, Place of Disposition 21)1Q();Net.) £/?2,Arz 7 2 (address) LU - - (I) Ce (section) (1o3,number) (grave number) - fl Name of Sexton or erso in Charge of Premises �.w a- I t r� 6-w I (please print) 44 Signature Title Gram c,, -r- - (over) DOH-1555 (9/98)