O'Neill, Hilda I Co 1
NEW YORK STATE DEPARTMENT OF HEALTH .I •
Vital Records Section Burial - Transit Permit
sit Name First Middl Last SeIt"
Date of Death , 113 1( Age If Veteran of U.S.Armed Forces, .
7 War or Dates
Place Death Hospital, Institution or
Z City Town Village 1 __2 ,--, _ Street Address •
0 Ma eath Natural Cause 0 Acq/8eri 0 Homicide Q Suicide Undetermined Pending
i Circumstances Investigation
119 Medical Certifier Name 13L Title
Address _
•f:-�� i �•Kn„^ br. vt Q�.t.2ns�-,r A) 1 ) AV47
al Death -l i icate File DOPic,t Dumber Rggister Number
iii C. ,Town or Village L c s) 1,,,— -- (g S ? 1 ,� c
Date c j Cemetery or Cremat
❑ l Burial Ia I 'y./a�,1f ,`nc.V c,..., • M.,-1.r
Address ` ?
Cremation (...0.LA,�e�5 a r A ,•,,, r c I .
Date Place Rernoved
Removal ' Q 1 and/or Held
0,Z and/or Address
Eft Hold •
CoDate l Point of
0 Transportation 1 Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
0Reinterment Date Cemetery Address
_; Permit Issued to Registration Number
r Name of Funeral Home-� S Alr �e r,.L 4->M e) -4,� _ oo,-t.Y'V
ggi Address
.,Sly F: , Al r 1-a t am
ti , e rc� . A-v
a Name of Funeral Firm Making Disposition or to VIhom
Remains are Shipped, If Other than Above .
1,4 Address '
Permission is hereby granted to dispose of the human re ains described aboive as indicated.
iil
r<v Date Issued 1 c-1 1 t) Registrar of Vital Statistics ei, 03 ri ..J—
(signatur
-C ( 0
el Dii!zigistrict Number �Cc�) Place
I certify that the remains of the decedent identified at3ove were disposed of in accordance wi Permit on:
H y�
Date of Disposition PP41Sj7bi` Place of Disposition .1 J,V ki,J Camho{ortuh.
(address)
C (section) (lot number) - (grave number)
Name of Sexton or Person in Charge of P emises �if i IAc . S,. l b w
ik (please pant) 1
44 SignatureCi
Title OE A Kra.
(over)
DOH-1555 (9/98)