Alsop, Ruth # (L
NEW YORK STATE DEPARTMENT OF HEALTH 1 "4-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
1 /1h 5
Date of De th Age If Veteran of U. med Forces,
I0/7/1K /Ji 4/V War or Dates /1///f
Place of Death Hospital, Institution or
5 C)ty, Town or Vi�lage Mg) Street Address M)f yfj,�J 7 ,e,,,/ -
Manner of Death Natural Cause Accident Homicide Suicide ndeterm ed 0 Pending
ILE Circumstances Investigation
tu Medical Certifier Name Title
a Jri oe///�///2- ilr-
Address
OW
Death Certificate Filed / / District Number Register N tuber
CO, Town or Vi ge rldd li/ 074
,❑Burial Date Cemetery or Cremato
❑Entombmen� / / P/& // ) /ir7i7diki , -
Address Ji ll/0//- �A(f ,b ily /�/ //s /
[ Cremation ,�
Date lace emo e
mow'ri Removal and/or Held
1 and/or
� Address
Hold
0 Date Point of
filti❑Transportation Shipment
O by Common Destination
Carrier
0 ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home / /`2r,// ' ' ///7 /
Address
7,7 /1;4 IV' Q ig,d9W 44/7)77/IV//cf
Ei Name of Funeral F rm Making is position or to Whom
• Remains are Shipped, If Other than Above
• Address
i
Ili
tu
Permission is hereby granted to dispose of the human remains described above as indicated.
giil Date Issued fri)/.15.i Registrar of Vital Statistics ,
(signatur/
District Number y<l77 Place 7/M # /)/,�
.I cI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
141 Date of Disposition Place of Disposition
(address)
Iti
CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises
2 (please print)
i Nii Signature Title
(over)
DOH-1555 (02/2004)