Fritsch, Nora NEW YORK STATE DEPARTMENT OF HEALTH �y #I Z
Vital Records Section Burial - Transit Permit
o Name First Middle Last Sex F.
N
o.c f\' ;l-sc\
`-- Date of Death 3p� I Age 1 If Veteran of U.S. Armed Forces,
OO I�� S i War or Dates N 10
Pia a of Death I
c Hospital, Insttution orZi TVillage '[`Q} �� Street Address ��.Q �qt L` S�a 7 zi I
.. Manner of Death Natural Cause 0 Accident n Homicide ❑Suicide Undetermined C Pending
Circumstances Investigation_
AI Medical Certifier Name Title
Eri C 11 et'i v 1-,1�
Address
\0 C a r\I--- sL-\-- CsIt S \tsi N‘" 12-,SD)
Death Certificate Filed ; District Number I Register Nu r
;'Town or Village C\.enS 1\\S i ,SGOI
Date I Cemetery orcrematory
❑Burial ) ) �\S e� � V i elm �V er'ld }pr
Address
lACremation �. c.0, ("",,..x_m,,c,s\ok,„,,,
-1 \Z501--/
Date I Place Removed !
e' ❑Removal ': and/or Held
and/or Address -- — ----- - t
Holdtb
0 Date --- _ _ -_._-------- wine of
la0 Transportation Shipment
a by Common Destination
Carrier
—
Disinterment i Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to j Registration Number
giiiR Name of Funeral Home baY`e.Y' -'u'n era 1 -\om�. - I o\'3o
igi
Address f L_"-
1\ La.cc NI e Slc-re ea-- Q v.eersbv,r-/ , N`f 12 oy
iiiq
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address Ng
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3)2_g I 5 Registrar of Vital Statistics LA) Qi._& ,/`f,M
(signature) sAV
a � Cl
' District Number S�1 Place 6�vs \\S l IN
I certify that the remains of the decedent identified above were dispos of in accordance with this permit on:
ii Date of Disposition /13I 1l!S Place of Disposition f L7-4.44,/
2 (address)
in
fL (section) i lot number},. (grave number)
24
Name of Sexton or Person in Ch ge of Premises /1 1nneit
(please print)
//
41 Signature Title Cft 'p,/(,
(over)
DOH-1555 (9/98)