Hartman, Scarlett _.-.- .. # 8 I0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
j e/iPLG-7T 1€OS6-- �Q)-)2,,.,,, 7--
Date of Death Age If Veteran of U.S. Armed Forces,
///jam/�2e/S — War or Dates
Z P =-- of Death / Hospital, Institution or . P",eA -SY%
own or Villag�/�/�� Yj, Street Address �p��i�j a /U /a ��/
anner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermi ed In Pending
W Circumstances Investigation
ul Medical Certifier Name Ai//7e'/e h2 d/J i Title
QC- 4
Address
7d L5d-v 2-1(, 6 4.21 i .,S 4/7,9)W
D h Certificate Filed District Number Register Number
Town or Village6Ye,75 �r//5 566/ to
0Burial Date Cemete or Crematory
['Entombment /*/ /,/ �- /`S A/6 U/( ' c/QSi'!7/9T4%2y"
Address
'Cremation 6vC/t e,2,hu,y 'A// l07f0C/
Date Place Removed
Removal and/or Held
and/or
F,;,,; Address
t1
Hold
Date Point of
5 0 Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /4/ZA'6'- /L-- -X42 /4 7)?G^ g/Q '19
> < Address
/36' /9%,0 Si, Sit. G/, s/ t//J MC/fir/
IR Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above .
2 Address
Lu
` Permission is hereby granted to dispose of the human remains describ d a s indicated.
/p2.`�/Date Issued /� Registrar of Vital Statistics ./-i 1 ' �, &
(signature)
Til District Number S6 p/ Place /.ew5 a_c/vy, /72r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
n
w Date of Disposition j,/�3 id" Place of Disposition gnu Crimwtot'iw.
2 (address)
Lu
CC
CC (section) N (lot number) (grave number)
CI Name of Sexton or Person in Charge Premises C `'r'� S�"fit
A
( ease print)
114
Signature Title (114401.
(over)
DOH-1555 (02/2004)