Klitin, Catherine NEW YORK STATE DEPARTMENT OF HEALTH 4-0?
Vital Records Section Burial - Transit Permit
Name First � �� „ Middle Last f -� �- Sex ___
Date of Death / Age 1 If Veteran of U.S. Armed Forces,
fl •Z ` Zo 15 T7/ i War or Dates
}' Place of Death I Hospital, Institution or , n
City, Town or VillageCity of Albany
v�
Street Address -AV(
,� C
1 Manner of Death�-Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined riPending
Circumstances Investigation
Medical Certifier Name Title
GA-61,y 4/1 ‘1,Ge_ 1\.)
Address
1111}
Death Certificate Filesit o ' Distri tNll mber ]( Regis r Number
<> City, Town or Village y f Albany c10I
Date Cemetery or Crematory
❑Burial 6 _ zcI' is i e id V 11 t) c (A1
Address J
remation (A)u6 ' I t N
g ! Date I Place moved
0❑ Removal , and/or Held
N and/or ! Address
-- Hold
Q j Date I Point of
NTransportation j I Shipment
a by Common Destination
Carrier.
Disinterment Date ' Cemetery Address
Reinterment Date ! Cemetery Address
Permit Issued to nRegistration Number
iiN Name of Funeral Home cone656(QfJ'� Fail c C E i ac,36-1-
Address
& -14-Ve-, 6„9-gii--1-w- Spis, iv( ize6-4
i,u Name of Funeral Firm M ing Disposition or to Whom
0 Remains are Shipped, If Other than Above
aAddress
Permission is hereby granted to dispose of the human remains described a s indicated.
Date Issued /Z 7/ Y5 egistrar of Vital Statistics�� X.r.�_-- 7
(signature)
District Number101 Place Albany Police Department Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Cs4.9=t5 Place of Disposition Trie tii,e,,j C..rora,c.tar i'dam►
!, (address)
LU
N
cc (section) � of number) (grave number)
0 Name of Sexton or Person in Char of Premises //rn -'-t,�.,// 13runej/e
Z ----� (please prirft) ,,//
t Signature Title Cr()rAleisr /ASS'/-
(over)
DOH-1555 (9/98)