Kuhnen, Betty NEW YORK STATE DEPARTMENT OF HEALTH t tf It
Vital Records Section a ,. Burla! - Transit Permit
Name Fist _.idle Date of Death fast Spx
Y Age If Veteran of U.S. Armed Forces,
c37 — a, I — JO Ic- 2/ War or Dates A/C)
• Place eath Hospital, Institution or /
City Tow r Village tiar Cci/Yi 6 Street Address-- •,/ 0 hl /1 AJ /- Ci ,
Iti Manner of Death •atural Cause Accident E Homicide C Suicide Undetermined I 1 Pending
Medical Certifier (Vamerj ia .e1)/it.)
— /Aid Circumstances Investigation
irti
Tj$ler
Address
If Sp ors b r kie cam`co►41,6 M.7. /err 3 a-.
Death icate Filed ' District Number�„ Register Number
City, own Village /L� -,Ce!/�'J /S ...3
Date Cemete or Crematory
❑Burial 07 _ a/— aO 101-- I (T/Ne-Lile_0 &1-se'VA rir
,,� Address
remation 0 U!e_e /v)36 LI Y` Ai
Date PI'ace Removed
2 — Removal and/or Held
and/or Address
L. Hold
0
O Date Point of
N _Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<< Permit Issued to 4 + / 1 Registration Number
7
Name of Funeral Home Ed,..o /� ,;----di L el/ Al e rig r/Nob, 0c7,, i 7
Address /n h W /c.v-- tit /c2 CF 7V
'>` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ltt
Permission is hereby granted to dispose of the human remains escribed a e a in icated.
Date Issued Q 7 — Sr-do( Registrar of Vital Statistics (,id,i ` IL
(signature) U
pg District Number /5 tj Place Af4,./L o rn (, ni.S. f a s 5 a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
, jj
E Date of Disposition i-titi1(L Place of Disposition Uti� Cie► -orluti,.
2 (address)
LEI
a (section) Aat number) C (grave number)
• Name of Sexton or Person in Charge of remises rr � ""
z a4i,- (please print) i
U. Signature Title Cn-fret
(over)
DOH-1555 (9/98)