Hilton, Linda ' # 2rb
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First , Middle ast Sex
H114-0 ,
Date of Death Age / If Veteran of U.S. Armed Forces,
L/ — 3 - 2 U i b 7 War or Dates
i Place of Death Hospital, Institution or
Z City, Town or Village 5(4✓'u`�C,C 6P. Street Address .50 ra i•-o5ck_ A/04 -
Ill
Manner of Death w Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined Pending
tij
V Circumstances Investigation
la Medical Certifier Name f) V Title
I." ) A DOC-1-N'
Address
5 ill li vs+ 1 ,e 51 , 5=5. - V Y i2sGc
Death Certificate Filed District Number Register Number
City, Town or Village SO )7
[]Burial Date 2 , I S Cemetery or Crematory ,
:: 0 Entombment Address /� " /; I p�
Cremation 2 ( Q(),_0 i�b ik(9) U((/ to S KJ c.t /
Date Place Removed u '"
Z Removal I and/or Held
9 a and/or Address
t Hold
tIL
O Date ' Point of
135❑Transportation Shipment
C by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to /_ Registration Number
Name of Funeral Home Gn do pa SS i ovi k akiAte, Cee"e? Mtn c_ 0 0 3 6(/
Address
L/v 2 rvi c‘p it 4 , Sic 5,0 12Y l L6 67
Name of Funeral Firm Making Disposition or to Whom
4;- Remains are Shipped, If Other than Above
2 Address
{r
W
t3. Permission is hereby granted to dispose of the human remain s de cribed above as indicated,.
Date Issued II'S— /S Registrar of Vital Statistics ' di't ". ' �r- .
Ai (signature)
District Number L(S—O ( Place -Sa•'' c S I • Y / 2- &CC
.14
;_> :: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Li t1!is Place of Disposition ['nt C r:,`or,...!
2 (address)
LICE
#3
>r (section) f� (lot numb`) (grave number)
CI Name of Sexton or Person in C rge of Premises it raft. SIiAb-
� (please print)
Et SignatureX Title «0e+-114.,
(over)
DOH-1555 (02/2004)