O'Brien, Deborah NEW YORK STATE DEPARTMENT OF HEALTH iffir
Vital Records Section Burial - Transit Permit
Name First Middle'� Last Sex
e- ;ba ra /
M . O' l x r t e r� I �-✓Y►a
Date of Death Age If Veteran of U.S. Armed Forces,
10 - S - 11 58 War or Dates kiD
1-; Place of Death (�- Hospital, Institution or
own or Village s - ..t_l is Street Address G k - 3 f
WCiq I IS psp l+4
O Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undeterminedll ❑ ending
t✓U Circumstances Investigation
tu Medical Certifier n Name Title
0 pher-e Spo nzo Mb .
Address r
Gie-r1S l'0..It Kid
Death Certificate File 3 District Number Register Number
it Town or Village(-, l(s ca 1 is
❑Burial Date Nmete‘ry or Cre tory
['EntombmentI D ! 1 l- 011 f 1 Q 10 Tern -o(Li
Address
'®Cremation D uet;r>sbuT NM
Date J Place Removed
Z❑Removal and/or Held
2 and/or Address
i= Hold
CO
O Date Point of
Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to A A, 1 I � �2t-�L�.�GZ .�� Registration Number
Name of Funeral Home , 01191
Address
1o35`l S4 a; e. I. 3D ) nd t tuN / J L/ OSLO,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Ili .
Permission is hereby granted to dispose of the human remains described a ove as in• ,-d.
Date Issued i0-1\-1\ Registrar of Vital Statistics
(signs ure)
District Number L5-60/ Place ;_
I certify that the remains of the decedent identified above were disposed of in accordance with this ermit on:
k
ui Date of Disposition 1 C-11 -3 o i l Place of Disposition t',rpe j;e w C %2 wk,,i0 r• v c'►'1
W (address)
til
CC (section) (lot number) (grave number)
ta Name of Sexton or Person in Charge of Premises ( w-►t.A 47 (�C'�i c'it c
Jam^ ;1 (please print)
W. Signature &4.4. � , Title Cfeenjofy 6s5-
(over)
DOH-1555 (02/2004)