Bristol, Betsy } 0 Loll
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Zrst Middle ' Lasi;—j_ 6s 1Tr4intette
t/3it 1'�Date of Dk2._
t Ag If Veteran of U.S. Armed Forces,
War or Dates ��, �
.-. Place of a t ( /( Hospital, Institution oVV
City, Town or illage "I t� Street Address f.�1s ���
W Manner of Dea • TA Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier N me
iota
vit .
i eT -. ci th PvY I1 .
Death Certificate Filed District Number �e ister Number
egister
Town or Village kw"( 6 7 I S
0 Ent ial rnbm t Date , � i,U t-or r j )tor
�E,............e�. Addres E 1�W
' 771,1Cremation ���J ► ��"(� Kl- A Q04.0i369 `�Date Place Remove "
Z❑Removal and/or Held
and/or Address
H Hold
Q Date .Point of
U Q Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
El Reinterment Date Cemetery Address
Permit Issued to �i ' A^ Re fist ti tuber
Name of Funeral Home çr\ +4j /f L Q
Address 14. � S . Ylk 1 vIlial
VVV ���/// t
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
Cr
Imo, •
P" Permission is h reb granted to dispose of the human r ains described above as indicated.
ild Date Issued Registrar of Vital Statistics LIY U�lr�✓V\
(signature)
District Number5743. Place ,! 14(9_ V- II- I E
"" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
#-
Z ' i
al Date of Disposition t•-b-t2 Place of Disposition �1i to..., �y. Troy i W,•,
(address)
ii l
VI
CC (section) (lot number) e (grave number)
Name of Sexton or Person in Charge of Premises /')r �e i�tf'
(pease print)
la
Signature Title CI'"€PI AT at.
(over)
DOH-1555 (02/2004)