Simmons, Caroline NEW YORK STATE DEPARTMENT OF HE, y l , 31,5
Vital Records Section Burial - Transit Permit
Name First kiddie Last Sex
("..`1 col 7 ta,` fie e i i![ttI1()(la; 'Wean l
::: Date of Death I Age If Veteran of U.S. Armed Forces,
- 7,-2 01 `I I 72 War or Dates No
Place of Death rx_:�kaaar _ Hospital, Institution or ,ttls_a as ter,
1.n. of Dune p 11 S 1 .• van
City, Town or Village y Street Address r,a,kc3 t; orrg;,, NY
Manner of Death Natural Cause E Accident ❑Homicide Ei Suicide ❑Undetermined E Pending
Circumstances Investigation
Medical Certifier Name Title
Jatt ee North M1)
Address
ic)c) Sroad Si-... Ci n[lai 7°A1 aq New York 12301
`` Death Certificate Filed Dist, unpber R ister Number
:: City, Town or Village '1'xl, z_�r: Que. �r burY � 2 f
Date Cemetery or Crematory
Ell Burial 7-26-2011 Pins View Crematory
remation Address21 Quaker Road Queera3i ury, New York 12304
Date Place Removed
Removal Li and/or Held
i i and/or Address
M
Hold
0 Date Point of
u)Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home �' . '1� :i1((!t r '�az.ir 11 'loop,
01 07`;
' ' Address
1 :16 m<1:i_("1 St. :it nt--f 111 :?uti i'A ] Sg Nf� v' Yr)rk 1 `)nn
a Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
al
iiiI Permission is hereby granted to dispose of the human remai s described aboveas indicated.
Date Issued 7-2 6--1 1 Registrar of Vital Statistics C.t.-�_ G , ( 1LtA.__�
(signature)
District Numbvc
Place l'n. OF t)raeen .;bury, New Yor'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ire
ILI Date of Disposition Place of Disposition
(address)
LIJ
0
" (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
g (please print)
(.! Signature Title
(over)
DOH-1555 (9/98)