Barr, Karen NEW YORK STATE DEPARTMENT OF HEALTH 5-3-6
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex F
or cn 0. �o0r-r
Date of Death r Age ( If Veteran of U.S. Armed Forces, —1
W.
.:« 01 1 acr 1 2.014 51 War or Dates N I A
''}` Place of Death Hospital. Institution or
1
Citty, Town •or&lag 1-Judson Fct I is Street Address 2.Z �rr`( S. Ap*. R .
Manner of Death 2 Natural Cause I I Accident D Homicide 0 Suicide ❑Undetermined Pending
_ Circumstances Investigation
Medical Certifier Name Title
r'C► � t- �r�bYoS
a'oar' M D
Address
10 z- Pa rAIN S1-cc A G 1 er,,sFa 11 S i N.Y. 1 2 Ben 1tr: - - j
Death Certificate Filed I District Number Register Number
City, Town or�dle H v don 4\\S-
Date Cemetery or Crematory
❑Burial o1 1 28 [ d.0 1 " _T nc_ Vi euJ 'C ca e
Address ,�
®Cremation Q. o,`t%.sv- Q Q o•,ca _C' ..ee�nSb u-c 1 t i j 1 Z$O i l
Date j Place Removed i
Removal ; and/or Held
r, and/or - - -------
Address
! Hold
Q Date 1-Point of
IA Transportation i Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
[]Renterment Date Cemetery Address
�yt ry
Permit Issued to Registration Number
Name of Funeral Home Hai/Mr-CI b: &akel Fu-ne,-a.J home. Of 30
ig Address // Lafa.y to c3f. , Ob .e rnSbc-LI J , /Jew t-/vrk l c2eol
Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
Address
41i i
: Permission is hereby granted to dispose of the human rem ins described above as indicated.
w Date Issued 7 1,2_e/4, Registrar of Vital Statistics C• e 1 n.
1 (sig ature)
A` District Number ) 6 Place 11, //a f� (}- /46, c/s-opf Tq 1/S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition ,/LQ jib Place of Disposition rN,
* (address)
ii
CA
#r (section) (lot nu r mbe (grave number)
gName of Sexton or Person in Charge of Premises ht J tn �
//}} (please print)
jW Signature G� Title r
(over)
DOH-1555 (9/98)