Ostrander, Ruth NEW YORK STATE DEPARTMENT OF HEALTH "y` 7t 373
Vital Records Section Burial - Transit Permit
Name first_ , Middle . 0 Ser
Dat f De- Age If Veteran of Urmed Forces,
"'" 5 f0 /S �' . . A
1 War or Dates
14. PI - ...'.eath /� �� � Hospital, Institutio
Z Ci . Tow or Village e ( Street Address -11(1460 iliiit.ainq -111,0 e--,
Mann- of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Padding
W. Circumstances Investigation
tu al Certifer me Title
I; I. bf&-
Ad
dress
N:i! 31-7 .64 botvicAGLA red L rdWout ny igsees-e-
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Deati - -4 ificate Filed -/ ' District Num
b4r mber Register Nu ber
Ci , Tow or Village �A�-� s.„) _ ,� ,c7S
❑Buns D t C etery or r matory
❑Entombment a� jo/� / " V 1..,2'c.�-, C(-e-
Addres
!cremation UII 0 , r /0-1 "(�/'
Date / Place Removed /
ts❑Removal and/or Held
and/or Address
F= Hold
0 Date Point of
ei❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to J /� Regis/Z.;ifyi
��
Address et-;i1 k5L-, ,S. &EIS a��s / , ` / g
Name of Funera(Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
ill
Permission is h reby anted to dispose of the human re ' s described ab ye as i dicated.
-
Date Issue Registrar of Vital Statistics
_________ (signature)
arDistrict Number Place �L�,.� _ Q�
"' I certify that the remains of the decedent identified ab a were disposed of in accordance with this permit on:
LFf Date of Disposition S/27MMS' Place of Disposition eCt Ci.•-fi,r4._
(address)
te (section) (lot n mbec) (grave number)
0 Name of Sexton or Person in Char a of Premises IA1
fc arrr
A, (please p nt)
1 E Signature Title Atoll/pit
(over)
DOH-1555 (02/2004)