Goldbratt, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH f^ 1 /l
Vital Records Section Burial - Transit Permit
Name First ( Middle / i Last Sex
E ti 1 V\ (701( b_t_ Fr i-
.� < Date of Death Age If Veteran of U.S. Armed Forces,
4.
2 — j /5" S War or Dates �/l
Place of Death Hospital, Institution or .
City, Town or Village A r 7 I e_ Street Address a.S i�tv 1-c G`�'1-'kr
Manner of Death Natural Case Accident Homicide Suicide Undetermined 7 Pending
Circumstances Investigation
LI
ill Medical Certifier Name F.14LG ( Title ��^46.rb, GG v.
3 G- .1 A1rbef-t 54 . 6-hki r^ilot it 1 2-8 ( C
Death Certificate Filed District Numbef Register Number
>> City, Town or Village 5750 A
' > DBurial Date -Cemeteg or Crematory
iiii ❑Entombment Address xis -
,� �� 6? �n
1Cremation x/ a t�tti.l�l l 21) . (-(e P$`s 1 c do_- y i
Date Place Removed
D Removal and/or Held
and/or -Address
kt. Hold
i
0 Date Point of
ori D Transportation Shipment
5. by Common Destination
Carrier
0 Disinterment Date Cemetery Address
iii!iliiiiD Reinterment Date Cemetery Address
IF
Permit Issued to r Registration Number
Name of Funeral Home 1 t 5 i�a V.v i-€- rat vtevc iJ 6v-E O G 3 c c`
Address
igiiii Name of Funeral Firm Making Diposition or to Whom I 2$(C
• Remains are Shipped, If Other than Above
• Address
I
lid
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 2\ 2�15 Registrar of Vital Statistics N Lian ,,,,,_
(signature)
id> District Number 5 7 s, Place CAA,21 i t n
e I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
etc 1�. C Date of Disposition 3�yiS� Place of Disposition �.-r
`: (address)
w
CA
rt (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises (ram tm
Z t ( lease print)
SignatureL Title t "I t.
(over)
DOH-1555 (02/2004)