Kellberg, Ethelda NEW YORK STATE DEPARTMENT OF HEALTH ',
Vital Records Section Burial - Transit Permit
Name First Middle Last ex
Date of Death _ O ' Age If Veteran of U.S. Armed Forces,
3 Z 3 Z S War or Dates P I
} Place • Beath Hospital, Institution or / ` Q
Z City own )r Village m U Ire(A.(J� Street Address /-1O title oF f hQ etepLe rr/`
MI
Manner of Death I�i Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined �Pending
Circumstances Investigation
ta Medical Certifier Name � �� �Q�$ Title d____. �C
(45
Address
We.S1- 11OLe- , 5 5- 7p ,. AY / 78C6
Death Certificate Filed District Number Register Number
I<> City, Town or Village y SG,2, /y
❑Burial Date 2 Cemetery Crematory
3 � I Cr c v(
❑Entombment Address / )
remation u,x i2 Y `'j
� 2 I Q Z2.�- ��c�b�� /U�
Date Place Removed r '
Z❑Removal and/or Held 4 2 204
2 and/or Address
t Hold
U
0 Date Point of
Oi❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
iig Permit Issued to �� `_ Registration Number
Name of Funeral Home ary-N pc.65;c ` - &re— U 0 3 6 9
Address k
-- /9 Ve - /
Name of Funeral Firm Making isposition or to Whom rr
Remains are Shipped, If Other than Above b
2 Address
t
to
:1` Permission is hereby granted to dispose of the human remains described above as indicated.
ai Date Issued -/ al 51/5� Registrar of Vital Statistics 4Lba/nr1u 4/ `�
(signature)
District Number v sz, a Place je 6,0 0 F Ad I e41i S/ ,Er 9 no, ij , d ,)k,Ccg4,
I certify that the remains of the decedent identified above were disposed of in acco dance with this permit on:
1'LI Date of Disposition 3-4f-A Place of Disposition j/),r1.7/ 4:,..41/ e-4/9/Pii,tj/
(address)
ILI
11 (section) N.(I t nu r) i 1 (grave number)
el Name of Sexton or er Charge of Premises
(please print)
Signature d TitleA/,9 Cinciktd44 O.
`' (over)
DOH-1555 (02/2004)