Haskell, Barbara f ,---14f tJ
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section . Burial - Transit Permit
Name First° i addle L�i�tt Sex
Date of Death Age If Veteran of U.S. Armed Forces, ,
`alit l/ TS- War or Dates
Puce • •-ath , 6 A ` At, n p l�t/7
Z City/ own �r Village Gef��,���C Hospital Street Address
Institution or5-
Ma • Death Natural Cause E Accident Homictde O Suicide 7 Undetermined Pending
LL Circumstances investigation
0 Medical Certifier Name Title }
q 7-►A „Cor 11. •
Add jss C.Jt lv14- 0,4t%Ct. ( f CarD At Q,.�u45b.•w�/ NT
I:. ( Death C . ate Filed District Number Regiser Number�IC,ty. illage �r,,, �s-c) i
Date Cemetery o ematory
/7 Burial i ' l`f f' ,At v'1••^' 64r14,•a
Cremation Address guns /_�r�`� A.) w� l
Date t' V Place Removed f'�
ZO Removal and/or Held
and/or Address
r— Hold
ODate Point of
Transportation _ Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
— Reinterment
Date • Cemetery Address
Permit Issued to � Registration Number
Name of Funeral Home bi►SMorc_ _/ ,tetv, 1_ H-f''- Q0�
Address a,. v
7 � cr.►• ,� /-ve C. • - lv - l a> 1
Name of Funeral Firm Making Disposition or to Whom '
N Remains are Shipped, If Other than Above
Address
Permission Is hereby granted to dispose of the human r a ns scribed ov Icated.
Date Issued f°/ i/ //Sr R4istrar of Vital Statistics sue^ X.14 /
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District Number iI-S c Place CD(' '1-6-1‘1- PG-t—> J,MI/\
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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t? Dale of Disposition is/rK/is a Place of Disposition � Cr cr*--
., . (address)
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cC (section) i�yy(lot number) , (grave number)
Name of Sexton or Person in Charge of Premises (ha=1 L xi.. t-
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(please print)
w, Signature Title af, lig
DOrt•t 555 (10/89) p. 1 of 2 vS•6;