Bennett, Karen . �, # so 7
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
qi Name First Middle im Last S x
11
3 Date of Death ; Age If Veteran of U.S. Armed Forces,
00; -/ - / 0 - /5 ( '7 1 War or Dates no
Place of Death Hospital, Institution o,r,Ci , own •r Village ) r 1 q,,, L&k-t__ Street Address Z�
Manner of Death r Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
�r ►sfin .�acKe:,nr, f(Ph
l Address
1 Yld t o.r1 l 0 -1 Aq
Li Death rti#icate Filed District Number Register Number
*.0 City. Tows r Village I r,A t.a r\ 1. k 5
Date , - meter-Semetery or Crematory
ElBurial 0 7 ) )31 )5 f i he v l e,t o Cif,r40-0 C
Addr J
,Cremation O1,t t2.t15 6) n j i\J )a�Dz-`'
ZDate Place Removed
z Q Removal and/or Held
.- and/or Address
Hold
! Date ( Point of
Transportation 1 Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
II Permit Issued to i Registration Number
Name of Funeral Home M ► 1 l ( � i tiomQ (9 J i qg
f Address
(Q35-7 S :-fie t7 /hc1 1.. =w) L-c_. ' " 7 )2,gq,a,
33
M iX Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human ems ns descri ve as indicated.
k*'. Date Issued��'•� 7 ii. /6 Registrar of Vital Statistics
s
�—, n ( ' nature)
District Number ck1),5 3 Place /0 LA))-1 iel 1 !.(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1 Date of Disposition 11 I(l l s' Place of Disposition t«c14,4 Crier&..►
(address)
to
(section) (lot numb ) (grave number)
.§
Name of Sexton or Person in Charge of Premises ((n yit, t
z
(please print)
W Signature4 Title rC z,r*(-T70._
DOH-1555 (10/89) p. 1 of 2 VS-61