Stadler, Barbara NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir Mid �� Las / Sex.
Date of Death Ag- If Veteran of U.S. Armed Forces,
/ /LT--- War or Dates
I- Place . :-ath Hospital, Instituti
Z City To • or Village v, /-70,�, Street Addressi/ 4 4/=1`� /f/ rC)/!/i/
W Manner of Deathrrl Cause ❑A 'dent El Homicide El Suicide ❑Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name -- Title
Qy
a )- 'yi/-7{?T c 6s-7r�cc2.<,7 ..L
Addrgss
/72— —C--', -;- A c.,g,17 ,R,.,, , _ I/, (°g. '..7&73 -,
Death ificate File` District Nurbeer � Register Number
City(1 or Village V ./ /75" i✓i , ?, � Co
El Burial Date , Cemet ry or Crematory 2
❑Entombment` /`r 2h� l-eG{-/ C , 2.-,/7 C�/C5C//,�L-z/
Address - /
:]Cremation �(�-��Z ,f �/,� A�`d' ��
Date PI Removed
Z Removal and/or Held
' 2, and/or Address
F- Hold
t1
O Date Point of
ti❑Transportation Shipment
d by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home4..?C j!�-- -/f 07,7 �� 7 /q-
Address , — / /--� J/
i//7_, X? /42,1/-4
Name of uneral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
C
LEI
11` Permission is hereby granted to dispose of the human r= i s described bove as i d' ted.
J
Date Issued 5 . OXA- S Registrar of Vital Statistics .i Q.
( ignature)
District Number,54 SS Place k.C� , .,A ..._t `\ \rS
1—
I certify that the remains of the decedent identified above were disposed of in accordance wit is permit on:
(1
l� Date of Disposition 6)log- Place of Disposition �,� ,s„/ ��oiry
(address)
ILI
CO
CC (section) j .(lot number(L (grave number)
0 Name of Sexton or Person in Charge of Premises ' 4,1•01-
(please print)
SignatureZ Title AIL
(over)
DOH-1555 (02/2004)