Kilburn, Theresa /y , g to 2-
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
_ Name First Middle Last Sex .
there a 6i2_eirx 6i ) bofn —
:`._ Date of Death . Age - If Veteran of U.S.Armed Forces,
1 2-1 'l I 5 $7 War or Dates M I
Place of Death Hospital, Institution or
ut
rct City Town'or Village Pi-, Street Address l l�CLS \i f\ Von �\t If"
Manner eath gi Natur se El Accident Homicide []Suicide Undete fined ri❑Pending
t Circumstances Investigation
ui Medical Certifier Name S Title (`n
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Address
L*513 3-k- . K,t . qo Pr ,E ti - t oef
>i Death Certificate Filed District Number Register Number
= > City, <to or Village 51 St, SY
II❑Burial Date Z1 t Cemetery or Crematory
o I 5 P;r3-e_ 1/, e LA) CrNer"a A-Dv y
1 Q Entombment Address
iiik4ACremation f y
i Date I Place Removed
Removal and/or Held
❑and/or# Hold Address
In
0 Date -Point of
4.4 Q Transportation Shipment
ct by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Q Reinterment Date ' Cemetery Address
= Permit Issued to Registration Number
Name of Funeral Home 1 winos ci ...(ja er Etiner a.t Cr4L. 01 I 30 --
> Address
i t Lacey e-He- S-k. , a i eensbur y , Ni e yc{ 12 c3 U LA
`<> Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
AM
Permission is hereby granted to dispose of the human remains described above as indicated.
girlli::: Date Issued VD. ` ) ) 3o15 Registrar of Vital Statistics p< `k.t_rU`°''
(signature)
r,iDistrict Number S�5c, Place I r
`` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i Date of Disposition f l l el i�' Place of Disposition gv...., rr 0rt&
a (address)
la
f
(section) if (lot number (grave number)
0
0 Name of Sexton or Person i Charge o remises `iint 01114
lease print)
Signature Title aQ-
(over)
DOH-1555 (02/2004)