Hutchinson, Diana NEW YORK STATE DEPARTMENT OF HEALTH '* i/ 31 Z
Vital Records Section Burial - Transit Permit
IN Name Firs Middle Last S
: 111ru fi M a`'l t NUITLI\x N so
Date of Death Age 1 If Veteran of U.S. Armed Forces,
iip 04 / $ 1 g_D t S 1 oZ ; War or Dates --
Place of Death r Hospital, Institution or ,
City, Town or Village `bitT -pk.--_,A�� Street Address ctcr u DSDrJ I`�'v�S 1 N c.
• Manner of Death ..Natural Cause 0 Accident n Homicide D Suicide 0 Undetermined FlPending
ill Circumstances Investigation
ti Medical Certifier Name Title
S f Address
0 AV_ G Lt �D ()-Ui LOS v � r t - \ C 1 0
iiiM Death Certificate Filed r District Number I Regiser Number
` l City, Town or Village v° -`-'A cz--D 51 65 [ O
C
• Date emetery o Crematory
` ❑ 1
t_:< Burial I: 1 LQl I , t— \J t.r �'1 Al AT -1
Address
FL Cremation A it-:41-- ��•-� r��6 E S fU�L N
gDate ' Place Removed I
fl❑Removal I and/or Held
-• and/or Address
Hold
0 Date Point of
mQ Transportation j Shipment
5 by Common Destination
Carrier
D Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I Registration Number
iiiiiii
iifgii J
Name of Funeral Home t aynard ker Fuiercd //ome- 01 1 '(3
lej Address j/ Lara Lie e . , btic.e.cnsbu ry 1/Jew l/%T)L l a'Ul
> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
-:<{ Permission is hereb granted to dispose of the huma m descri d v indicated.
Xli;iDate Issued '1( 1fLO I g Registrar of Vital Statistics r
(si9 e) r
aid
Mil S 5 5 Place 1 �"L(�7'l�
������ District Number
06
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i ®
F Date of Disposition 4I iBjlc" Place of Disposition -1 Cr.,'
r fon,-
2 (address)
14
U)
fl (section) 4(Ipt numb (grave number)
1/40 Name of Sexton or Person in Ch ge of PremisesCi ` orL, tom-
g (please print)
W Signature Title ( m tt
(over)
DOH-1555 (9/98)