Pitts, Nancy NEW YORK STATE DEPARTMENT OF HEALT4-I I ,7V
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Na}i 'L Oi445 Fe+, Ce-
Date of Death Age If Veteran of U.S. Armed Forces,
/ 2_ - 17 - 1 3 $' V War or Dates
Place of Death °' , Hospital, Institution or ' II
City, Town or Village ia_tr Ce• Street Address S wi f I G ra c �j Jr
is Manner of Death❑Natural Cause Accident 0 Homicide 0 Suicide El Undetermined prr(Pending
1U Circumstances V Investigation
Medical Certifier Name nA Tit)e
Address
/L'116 /Qe1 Si^ Kikic� ✓ oc4-et!`
Death Certificate Filed SARATOGA SPRINGS -.-_.." Number Register Number
;;;;;;sty own or Village 5 / 6—
>:< El Burial Date Cemetery or Crematory
1 Z—1 — 3 10r42 (Jt€(4) C 1
:m❑Entombment Address a
>:i g Cremation 2- KQ,✓_1 0 csk-C- ,, 1 c 4 / ! /Z80 y
Date Place Removed V
Removal and/or Held
and/or Address
i=` Hold
fit ,
0 Date Point of
ti Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address ` V (l.id Ire_ /9 (/^-e S. /(- l' / Z C
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
,'; Address
UI
` Permission is hereby granted to dispose of the human remains scribed abo a as indicate .
Date Issued 12-15_I Registrar of Vital Statistics irkY\ I *
(signature)
District Number Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � j,
III Date of Disposition ia-14,-15 Place of Disposition '�'ua.%) ,tifor,,,^,
2 (address)
141
ilk
CC (section) ?inuribtler) < (grave number)
DName of Sexton or Person in harge of Pr mises alr Jtir'�"2 4 (pleasprint)
ia Signature �— Title Ce nrrrr(�,
9 F c
(over)
DOH-1555 (02/2004)