Kilmartin, Therese NEW YORK STATE DEPARTMENT OF HEALTH •Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
7 NE CZ,C S t e. _\u-\ V_I,LM P T 1 C=
Date of Death, I AgeQ If Veteran of U.S. Armed Forces,
t , 1t 3 I i y _ -13- War or Dates
}- Place of Deat Hospital, Institution or _
W City, Town or Village &cG rwI \\e. Street Address �'I..-S)JA � ..\\) E K
W Manner of Death ®Natural Cause 0 Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
LU Medical Certifier Name Title
Address
tOb Pc,x-V- Si C.,\e s C.,As is--- \-1 k'ago ,
Death Certificate Filed / er u District Number ' Regist ber
City, Town or Village n1/ille ,57W5'
❑Burial i Date l f/ ik emetery or Crematory
❑Entombment (d 1 1 fo o�d i n 2 U ,2c.J_Ci'e _-,4 T0 r
® Address Q . , V� � h 1 �-' l��6 Lt
Cremation o v �� u-_
Date Place Removed
Z Removal I and/or Held
and/or
Address _
CAHold
O Date 1 Point of
aQ Transportation _ _I Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
Ei
Reinterment Date Cemetery Address
Permit Issued to _ I Registration Number
Name of Funeral Home t{6,1{i(,�,rd , i�ker ,%sicrc-1 iior - 1 0. 1 1 30�
Address
h talC yQ H . , u.e'Cn- \Lo,/v _tie v,I 'Air L 12`SU`-j
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
;; Address
1X.
W - - -- — -
0.' Permission is hereby ranted to dispose of the human rem -ns des 'bed ove as indicated.
Date Issued IJ"-% Registrar of Vital Statistics — „ ae/ - _
(signature)
District Number 5 7 5' Place 6r 77 U'#e
y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.
Date of Disposition l Z ighti Place of Disposition _ ;ni,u,J Cr ....
2 (address)
W
ffi
— --
O (section) (lot number) (grave number)
Q Name of Sexton or Perso in C rge of Premises ',rt.,'
„at
z (please print)
W Signature _ _ Title — C
(over)
DOH-1555 (02/2004)