Knickerbocker, Beverly 411417
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First I Middle Sex
S vef�r //1 it/.,V / /7/c/4 .),Z4-ac-- i-C
Date of Di / Age If Veteran of U.S. Armed Forces,
8 /�.G/2- • 7 War or Dates
Pla.e ofh Hospital, Institution a-p .,./.- a' own or Village Ck,/f /4 Street Address ,f//��/-C-/CC/
o anner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
ii,i O Circumstances O Investigation
W Medical Certifier Name itle
CI S, Z' e. /4�- h�-1 ;. V o
7�� ` �pddress �� 4 ✓l4/ /)-f/�J
J / /yte, h //azrl
Death Certificate Filed p / District tuber Register Number
, Town or Village 2 f/ '/ � 2/ _ f'
OBurial Date �j C7" - '
or Crematto� f /� •
OEntombment ��/ (- C-'� ( z SyrGt/c2/ivii
Address f Ol C _. �a� lam/
mationj/ � /�jvl ` DG/
Date Place Removed
g O Removal and/or Held
and/or Address
w= Hold
LC
0 Date Point of
11' Transportation Shipment
0 by Common Destination
Carrier
O Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to -� r-- Re istration N ber
Name of Funeral Home//6 — /1 C-c//*p/7 A /7' �
Address
r7- .rT /NC)w 77 /. /2
Name o Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
lE
a` Permission is hereby ranted to dispose of the huma�i remains describ above -- indi,ated.
Date Issued Q�1p� 0(� Registrar of Vital Statistics 1
(s nature)
��District Number 60 ' Place
J`-�;.L ��1 / ! I QV
I certify that the remains of the decedent identified above were disposed of in accordance with thi permit on:
Iii• Date of Disposition g-io-11 Place of Disposition R—ith .) Co.i fare,.
(address)
CC
C (section) (lot number)C (grave number)
0 Name of Sexton or Person in Char of Premises pt r JP"�
2 (please print)
Signature 3L1 Title (t€M' cO&
(over)
DOH-1555 (02/2004)