Adelmann, Julia NEW YORK STATE DEPARTMENT OF HEALTH r
Vital Records Section It Burial - Transit Permit
-1 Last
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Na F. Middle,
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Date Death Age : tf Veteran of U.S. Armed Forces,
(P `Cr ` ,2 9% + War or Dates 21,0
},;,, Place of Death i Hospital, Institution or
:laCity'li4 or Village )U Q -iL4k u_k.4, i Street Address ',E 51-d.4l i t
Manner of Death
rZINatural Cause Accent 0 Homicide Suicide
Name Title Undetermined Pending
Circumstances Investigation
mrib
_Medical Certifier
oslp-i Su colo-r
Addres
Sherman Alle. Quee sbur Y 12 w0
Death Certificate File 1 Dis t Number st r Numb
,, CitylTowr Villagetpae.k4ta,6 a A,�,.- C I ( I5
Date ( emetery or Crematory
❑Burial i _DOI0-7 ra rt( i(9.E.4
Address I^
2Cremationi • Lk� �L.t ,�.
Date Plac emoved
0 Removal . and/or Held
i" and/or Address
N Hold
0 [ Date Point of
as Q Transportation Shipment
G by Common Destination
Carrier
Disinterment ; Date Cemetery Address
Reinterment E Date Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home -ekQ,L,,)-CA �- 0(3 //
Address i
di- � urcH o a_ a �.___-__ __
Name of Funeral Firm Making Dispositi'n or to Whom
Remains are Shipped, If Other than Above
tl Address
W
Permission is hereby granted to dispose of the human r mains described above as indicated.
Date IssuedcD H ( I Registrar of Vital Statistics � Yam C 0
(signature)
District Numbec(Q c---) Place L„..4-v 0 �,.-,—�-
I certify that the remains of the decedent identified above were disposed of in accord nce ith this permit on:
1-
DIliate of Disposition (.iiIIL Place of Disposition f plifrw ��ryturiLw.
2 (address)
W
U)
c (section) Ai .(lot number)c (grave number)
0 Name of Sexton or Person in Charge of Premises h(,)t•j� Not
g (please print)
W Signature ` Title CIS rtq rt.
DOH-1555 (10/89) p. 1 of 2 VS-61