Fitzpatrick, Anna ��//
NEW YORK STATE DEPARTMENT OF HEALTH / „ 3 S 1
Vital Records Section Burial - ransit Permit
Name First Middle Last I Sex
Anne- F-1-7-pek+r;cY- I F
;; Date of Death Age If Veteran of U.S. Armed Forces, A'
o 1 ) Z1 ) Zo 1 W $1 War or Dates 'V
Place of Death Hospital, Institution or rd
City, or Village Gle(NS dal\S Street Address ZU 3 SI ree.4
Manner of DeattNatural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
Circumstances Investigation
IIMedical Certifier Name Title
gi 1 K_, Pok-roaf M
Addressligi lO Q rzS-1-- atr,f-,s F S . /U9 / Zpd/
th Certificate Filed District Number /- hegi er Number
<: City Town or Village £t(-jtrS F z,t S J [�o / 2 a
, Date Cemetery orcrematory
I !Burial O`, I Z5 7-0i1.9 QiC1P_ \j e prCmA.40ry
:» iK Address
-pi a Crematlo►r `ill Yl e V i e u.) - 9 p einsh ur i j 1V\1 _ v _ _ �._
Place_ Removed
Z❑Removal i and/or Held
.. and/or Address
C- Hold
0
Q Date Point of .
51.3 Q Transportation. Shipment
d by Common Destination
Carrier
0 Disinterment
Date l Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to _ _ ) Registration Number
Name of Funeral Home _ _ , RPX01 i &-n. / NG 0/139
>' Address / r --
!/ L lei L) /c�'` 7 , 0 0u2: IS 0, 1 " /leo .
;< Name of Funeral Fi Making Disposition or to Whom I
ed
Remains are Shipped, If Other than Above
aAddress
I
i
Permission is hereby granted to dispose of the human remains described above as indicated.
ill Date Issued Lit Z'24 /6 Registrar of Vital Statistics
(signature)
li District Number 5-60 I Place 6 Cvs V1 S ,. 1,1v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition `//Z /b Place of Disposition r r 1L., L1r-o --
2 (address)
W
CD
CC (section) of number) (grave number)
0 Name of Sexton or Person-in Charge of Premises Gig
-z (please print) f
Signature Title 711PwitilYL
(over)
DOH-1555 (9/98)