Bird, Kathleen , .
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NEW YORK STATE DEPARTMENT OF HEALTH -
Vital Records Section Bu r i a I - Transit Perm it
Name iFirst Middle Last Sex M 151 rd _ RirYla ICJ ,
1 Date of eath ' A e i If Veteran of U.S. A ed Forces,
(0-(cf- z.o t 4 '0 War or Dates
'}4 Place - seath I Hospital, Institution or
le City. Tow or Village I nsi(Of\ 1 Street Address
ri Manner of Death kvol Natural Cause 0 Accident El Homicide ri Suicide Undetermined Pending
tu Medical Certifi , Name , ...
n ATitle 1::Circumstances 'Investigation
Gto JcvAsun r. _
Address
I na tan L , , 41(x_te,attr i nei Lou/ .....44.k..
Death Certificate Filed i ' District Number ' Register Number
City Tor or Village 1 y)A 1 cLit LeLk_z_ 1 a 0.53 1 A
0 Burial Date etery or remato-:
-10
Addre
• 11Cremationi 1011-r j N
Date lace Removed
!
r r-i Removal '
and/or Held
and/or 7 Address
./..-
-ad Hold
thl
asp-
Date - Point of
a0 Transportation ' Shipment
a by Common Destination
Carrier
Date Cemetery Address
.' El Disinterment
Date I Cemetery Address int'
f : 0 Reinterment
Permit Issued to E Registration Number
Name of Funeral Home M i 1 ler- 1 oteq.?
_
a 11.357 aaf te e-- fe '312_1 ,Wk.,-___LVkii M81-
rOicei7
Name of Funeral Firm Making Disposition or to Whom
:14 Remains are Shipped, If Other than Above
'14 Address
itC
Permission is hereby granted to dispose of the huma re sins describ above as indicated.
Date Issued (e-;04"-- Registrar of Vital Statistics
ignature)
' District Number c-90.5.., Place ind(alti Lake/ Ay
,-'- I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
tu. Date of Disposition G/BM Place of Disposition
2 (address)
Mt
th
CC (section) d(lot number (grave number)
0 Name of Sexton or Pers in Charge of Premises
4 .t- eink,
z
/(---- (please print)
44 Signature Title afbIgnd
DOH-1555 (10/89) p. 1 of 2
VS-61