Guilder, Beatrice If s210
NEW YORK STATE DEPARTMENT OF HEALT4-1 j Vital Records Section Burial - Transit Permit
Name Fi s Middle Last
��T'( � Le L, . G J^v L
►Y`�t VQ
Date of Death f Age If Veteran of U.S. Armed Forces,
--i i c4 I e Ol 9 / War or Dates
▪ Place • Death Hospital, lnstitutioLL1c - -
or
,W City own a VillageOL S� 1 Street Address 1 kQ tf).-)c C, 1 r4i
Wa Man•- , •eath Natural Cause cc ent Homicide ❑Suicide ❑Undetermined El❑Pending
Circumstances Investigate
I�ii Medical Certifier NamS r Title
0 P--0 ''O-N c_c_)t o nm0,
Address f t)- (S// /
rn l Ln C (31...i.Zn 5,�.)r3 (� _i l !2S
Death i cate File � Dict Number Re ester Number
City, own or illage 9
l91-j�,� �� � ry 1
❑Burial Da~t-e-� ( �,.` reCrernato _
❑Entombment ! L f ) CJ��l �Q v` ,Q L, J 2 L` �^j(`
Address
Cremation Cj(..`ctes5j.,r 1 Pc-.) "rar<
Date U / Place Removed
Removal and/or Held
Z❑and/or Address
▪ Hold
IA
0 Date Point of
ihr ['Transportation Shipment
2S by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 215•,)rc_ J _11- �� 0 0 ` 11' .
Address - N� I I a.Q a
S�er*n.-.,. AV( Car, y—
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Z Address
Cr
lii
f.7 Permission is hereby granted to dispose of the human remains] described aboye� as indicated.
Date Issued O/c 0O Registrar of Vital Statistics '1ai G-- , (IA__.�
_ (signature)
District Number Q Place 1 0 ,__t_o_____ de_( - d-
I certify that the remains of the decedent identified above were disposed of in accord e wit this permit on:
1 Date of Disposition 7/ l((i s Place of Disposition g'-4 UtNel C1*-14-e"--
', ► (address)
11
w
CC (section) (lQt number) (grave number)
• Name of Sexton or Person in Charge of Premises ��
Z
Tease print)
Signature Ztil Title O? �'
(over)
DOH-1555 (02/2004)