Pitkin, Sheila NEW PORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firstf_ L� Middl� Last '})•�r ,� Sexes
•
Date of Deaqi Age If Veteran of U.S. Armed Forces,
(D 'a,o r3 71
War or Dates
, •
Place of Death Q Hospital, Institution or �t
Z City. Town c illagee ,r,:,A,--&t., Street Address 113 2eM,,, t- f- Y-e_
Wp{� Manner of Deg Natural Cause El Accident Homicide ❑Suicide �Undetermined �Pending
W Circumstances Investigation
W Medical Certifier Nam Title
O C.De Jr` -� &s:ti �l. �.
Address ,a
o P
� tL,er, Ave � ..�. N,ya)__. Ias
Death Certificate Filed //�� District Number I, Register Number
City. Town or Village t.,_ or:n�(,\ Li-6— -) • 1
Date Cemetery or Crematory /'
Burial �/I� la. oi3 i/teV..c.d 6 di-dor
Address
• -,Cremation LA,��5v4t A) , [ r<
Date V a Place Removed
ZO Removal •
and/or Held
H and/or Address
t Hold
O Date Point of
0 _Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home s.t ('e e_C.AL -{•skci 1,, c 00 1"ii?
Address
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
Lt.
Permission is hereby granted to dispose of the human r, • • scribed ov= -s ' •icated.
Date Issued g/f k 11 3 Registrar of Vital Statistics Ago .
" ' a ire)
District Number `f 5 a.( Place • 6,,-c � pe....) ��r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
al Date of Disposition _ 1 = Place of Disposition V( e
g (a dress) _
W
0 .
Et (section) (lot number) (grave number)
O Name of Sexton o erso in ge f Premises �� /�Gv� ,�,•,
Z (please print)
W Signature Ai d Title C-44►toei idc if:
DOH-1555 (10/89) p. 1 of 2 VS-61