Barbour, Patricia NEW YORK STATE DEPARTMENT OF HEALTH . `,4 I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex ,r.
vk Date of Death Age 71 1 If Veteran of U.S.Armed Forces, NI 114
War or Dates
5P :;- • Death c�� Hospital, Institution or
ilk)�`iii�° or Village �`-ter Street Address SLI O\d \ L'��.
T an - of Death ��� Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances investigation
Medical Certifier Name Title
V Gmu1-,G M 0
Address
�
Dea -_: *icate Filed District Number R isterNumber
City,l4 o •r Village -eenSbLufLA S/ 40.1
Date(DI
�� '��1 i Cemetery or Crematory
0 Burial `[ ?Nri e i c vo Crerva-Vbr-i
roil Address
:.e. Cremation a px Ar�j
Date Place�emoved
❑Removal _and/or Held
and/or Address
a Hold
Date f Point of
i[]Transportation 1 Shipment
. by Common Destination
Carrier
0 Disinterment Date Cemetery Address
:::::0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home/ iL/ and &, & Ref- Ft,t ieccl Home- Of i 30
L Address
Il Lana yyR C 3f. , &ckewsbard '/Ue w thy-it 1 a8vy
` , Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r in a-- .. "= t r .9< O�-rndicated.�
r' Date Issued���j� Registrar of Vital Statistics ,
tr ignature
h District Number 9jwc''1 Place pu v\ Cop.P4t Zo./A-o A
I certify that the remains of the decedent identified a were disposed of in • •- - with this permit on:
iDate of Disposition Place of Dispositio
(address)
S
CC (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises
g (please print)
f Signature Title
(over)
DOH-1555 (9/98)