Hutt, Frances NEW YORK STATE DEPARTMENT OF HEALTH 3/1
Vital Records Section - -- Burial - Transit Permit
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Name First Mid le ,,L��st Sex . _
y77 7--
Date of Death Age If Veteran of U.S. Armed Forces,
,/1/( 5'- 7 7 War or Dates /7
W- P e of Death Hospital, Institution or
W Cit , Town or Village ��e' S Cer�s�, Street Address ��kS '%
a anner of Death `,Natural Cause 0 Accident ❑Homicide ❑Suicide ri Undetermined . 0 Pending
W Circumstances Investigation
W Medical Certifier Name Title
Address
/te'/ . rii f e- lI' e-7_3 /,//d am
D--th Certificate Filed r D strict Numbe Register m er/
dr Town or Village �/ �5 / �S O/ a /
I ;urial Date / Cemetery or Cre atory /�P /'
/l/���5` V/7e 'e4✓' C / 2 lcT
El Entombment Address
Cremation v-6'e�,f y ,A /d cyG y
11 Date Place Removed
Z Removal and/or Held
3 �and/or
Address
I
Hold
0 Date . Point of
tch ❑Transportation Shipment • _
Ei ' by Common Destination •
Carrier .
Disinterment Date Cemetery Address
Reinterment Date. ' Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home G A S V A•%., re A 4r, ( 14 �� o n 1 Y f
Address . AJ‘( ) .`, . v
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
It. .
Lu
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" Permission is hereb" granted to dispose of the human remains describ above in d.
illIg Date issued ;t975— Registrar of Vital Statistics .
(signature)
District Number ,..5-6/-6/ Place Cle /7/j ,&y /;s- /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
III Date of Disposition 67,! /r Place of Disposition ,
(address)
W
ill
IX (section) /A (lot numberr * (grave number)ta▪ Name of Sexton or Person in Charge f Premises "` �
/ - J
mil► /jii (please print)
Signature Title eft irakl
(over)
DOH-1555 (02/2004)