Kenyon, Karen 2sq
NEW YORK STATE DEPARTMENT OF HEALTH s . "t Vital Records Section Burial - Transit Permit
K Name First Middle I act Sex
T—Ae G►`J RA�C i S Ii-Etna►J r
In Date of Death / Age I If Veteran of U.S. Armed Forces,
4 1 1 a (ao 1 s- 7- War or Dates
Place of Death I Hospital, Institution or
City, Town or Village I ? .V i Street Address 1> ( k SSE\Joc v`t C
MManner of Death gNatural Cause fl Accident 0 Homicide 0 Suicide n Undetermined Pending
,m_gil Circumstances Investigation
141
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Medilijcal Certifier Name _ Title
P I�bL LL. S\EL)E o, S
vu Address
;..j<, lvD ?GOAD S-T - tsaS. FAL —S K � j g-%01
t:; Death Certificate Filed ! District Number Register Number
"�' City, Town or Village `n0 CAL)
Date ( Cemetery or Crematory
❑Burial y i
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Address /� y
Cremation �vA�!CC-. VL, Zo A p 'Q V L E 1�Stu P_..y � N `t 1 D-SC 1-I-
g Date Place Removed
Removal _ and/or Held
M and/or Address
th
Hotd
0 Date -oint of
Nn Transportation i j Shipment
3 by Common Destination
Carrier
Date ' Cemetery Address
Disinterment
-:.: Reinterment
Date 1 Cemetery Address
ir Permit Issued to Registration Number
:= Name of Funeral Home Hc. yna rcr b: T aRer Fu ief cL/ /Dome.. of } c-:
11 Address li Lcfcildtc (31-. , bc,LCE OSk ,t.rLf , 1vew,v L%%CRC- la O
"`' Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped, If Other than Above
14 Address
al
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Permission is hereby granted to dispose of the human remai described a ove as indicated.
li Date Issued 4/6pc-- Registrar of Vital Statistics
<'`I$; (signaturZj.Z1%'
'`'' District Number aPlace ?S7 & j6s f 1Y& • / 3 a
y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
Li Date of Disposition_ q it p l5" Place of Disposition .gµ�. f,,-orx._,
a (address)
w
In
(section) otmberS (grave number)
Name of Sexton or Person in Charg of Premises (III ,14
g Ci 1 (please print)
t • Signature Title alEN-1y'c
(over)
DOH-1555 (9/98)