Feulner, Patricia NEW YORK STATE DEPARTMENT OF HEALTH
vital Records Section -
Burial - Transit Permit
Name First Middle Last
Sex
a � c- fil . l Get j•lt../Z.
Date of Death Age If Veteran of U.S. Armed Forces,
C 02) 20 lS� -7/ War or Dates
H Place • •-ath Hospital, Institution or
QZ Cit ,.r Village Co!`.ntt\ Street Address 7‘ `t Cs- Rol---25 -
Ma • Death ® Natural Cause 0 Accident 0 Homicide Ej Suicide Undetermined '-'Pending
LLJ
Circumstances Investigation
LiJ q Medical Certifier Name Title 1
L /4-. o; 1la1; i''i.� .
Address
i /07 PoliK 5. ‘ie-oi4-7.4/ /1). /.)V / ;
Death C-•' 'bate Filed District Number I Register Number
i City arr Village C�1,n - y 5-5--
Dale
H8unal
Cem e y or CrematorAddress r 7
tY cremation ke-CA vra ' ,�� . , / f
Z ^ Date Place Removed
Removal
O and/or and/or Held
� Address
R- Hold
O
a Date Point of
to Transportation Shipment
Ea by Common Destination
Carrier
— Disinterment Date Cemetery Address - j
Reinterment Date Cemetery Address
Permit Issued to _
Name of Funeral Nome Registration Number •
Address /) C/ A.1
/ Lo(•,, L Al,7 /a 1.)-.4___
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above .
•
rAddress
Permission Is hereby granted to dispose of the human r: - •:scribed ov: - • •Icated.
Date Issued its(•Z //5 R4istrar of Vital Statistics
.n1,.•a .re)
District Number 47"53-3 Place e, — / Alt_.,. `0i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 10 / ilrs Place of Disposition fwd.� �,„,c ,-
(address)
Li.)
CC (section) (lot numbe (grave number)
00
Name of Sexton or Person in Charge of Premises /4r,� r,- j,,,
il
ii,Z (please print)
w Signature �'' r�--- Title atfiAt
DOry 1555 (10/89) p. 1 of 2 vS•61