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York, Catherine
0 NEW YORK STATE DEPARTMENT OF HEALTH itt" 311 Vital Records Section Burial - Transit Permit w Name ^First Middle Last kyszr1 IV Y C�r 1C CC,(N0,-,LQ Date of Death) If Veteran of U.S. Armed Forces, 113 L -i 19 War or Dates F- Place Death Q Hospital, Instituti n or Z City Town r Village Street Address - & -O 04 ccy(; k Q Manner of Death Natural Cause 0 ' ent 0 Homicide 0 Suicide Undetermined E Pending (� Circumstances Investigatioc LI ill Medical Certi Name C 0)6 Re AA ess iii L...A-J'-‘2:Stcx-c)t.....>c-c4' '44 i‘-ooa_W,--.a-rsi-e,, (--Q- 'N.1/d ...C---,,e-P 0 O'Nj Deat - ' ate File District Number "��ARegister Number M Cit;, Tow or illage �9:� Cg� ii❑Bursa f Ce tery or Crematory 1 1� l Oi• C�c cr-$ ❑Entombment Addres jj 7 - remation iJl��l- . J S y t 7J = 1 1� Date j/ Place Removed Z 1---I Removal and/or Held and/or Address H Hold 0 Date Point of ❑Transportation Shipment 3 by Common Destination 4 Carrier iv ❑Disinterment Date Cemetery Address Reinterment iai Date Cemetery Address Permit Issued to Registration Number 14 Name of Funeral Horn_ S ,►,,��- fr H j "1 ©©,t'`t`{t Address Vur.r,0„.__ Ave 6!.wt- A. I,2YaL Name of Funeral Firm Making Disposition or to Whom / f- Remains are Shipped, If Other than Above 2 Address it lid d Permission is hereb granted to dispose of the human e ins descr' ed abiv as indicated. j 1. Date Issued�� L-Q ac.)lRegistrar of Vital Statistics. � /IA__ (signature) District Number�(9c----) Place 6 t _ Oc - r i I certify that the remains of the decedent identified above were disposed of in acc. :anc- with this permit on: Z � ��gg ��++ LU Date of Disposition -tt;ty Place of Disposition X,e.Lt,/�t✓ C••-4'--- (address) LU t (section) go t number) (grave number) ciName of Sexton or Person in harge of P emises f , 5-1414 Z (pleas print) LU Signature r-- Title CP4 v' (over) DOH-1555 (02/2004)