Guertin, Christine NEW YORK STATE DEPARTMENT OF HEA i i `
Vital Records Section Burial - Transit Permit
Name First ._ Middle I ast r Sex
C, 1."la (,v 13-1 ► / —
Date of eath Age If Veteran of U.S. Armed Forces.
£�� I E l 1c 6� War or Dates
Place of Death /� 11 Hospital, Institution or
City. Town or Village aLt..t..n5b u r Street Address a f-Q>(- 1.15(low L Ar..)>✓
Manner of Death r�Undetermined Pending'�• L. Natural Cause Accident �Homicide �Suicide I I �
Circumstances Investigation 4
Medical Certifier Name,.., Title
a 1,' \\. 1((�V-J6 C cb--Ne (
: Address -J ;
Death Certificate Filed District Number Regis Number
City, Town or Village t',)/(..,EC 1-)S$v Ry ,S6 S -9"
I Date (( Cemetery or Crematory
—Burial ca [03 1 �CO I S �c. vi — , CY�►si09._.-e,
—1
j Address
remation Qvp.g -C R isTD Q'-L E.NSi3vq---`'t fJ_
Date Place Removed )
Removal and/or Held
O and/or - — _._ __j
t;.; Address
Hold
th
Q _ Date - int _,i
0 Transportation Shipment
a by Common 1-Destination
Carrier
l i Disinterment ' Date Cemetery Address
• C Reinterment ` Date Cemetery Address {
Permit Issued to -- Registration Number
Name of Funeral Home A`/�-t-riC7 i Cr' L J CZ r r�. f-tCr rLI I/o: --
Address
II Laf Lc is :.)f , & ,ct.,-)sioctr(j ,tie.W thy'it %',;,)67G`f
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
r
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date issueo 1.3 I aO 15 Registrar of Vital Statistics - . id
O-1.it --k.�-k- i
--i
-I (signature)
District Number 5l9 5 1 Place _ V - e-n S v lj______
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Z`r1" ii- Place of Disposition n���, � '� _ {
ddress)
W
(sections(a
IN
(lot nu ber) (grave number)
la Name of Sexton or Peron in C rge of Premises i
,, .� -
EZ (please print)
1W Signature lll��� _ Title CPC-KIWI _
over)
DOH 1555 (9/98;