Walder, Carmella NEW YORK STATE DEPARTMENT OF HEALTH t /
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
ffii 11-uI -FAO I -a. (5 War or Dates f'4 p
Place of Death Hospital, Institution yr
ifi;C Town or VillageG Ier -t---Z�\k Street Address ,(/��j t. Us 403 i o I
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ElUndetermined b Pending
ILI Circumstances Investigation
at Medical Certifier Name Title
�h�i k n +ky k� b
adros
e itne.s \calks N) y
th Certificate Filed District Number Register Number
Cit Town or Village �� 0..( &t,o I c c
oii❑Burial Date emeterypr Crema ry�,l
❑Entombment I d- tp- 13, V1>rxI e 0e matt'
Addres
ie f Cremation uuuns bu rt N k�
Date Place Removed
Z ❑Removal and/or Held
and/or Address
Ll: Hold
f
0 Date Point of
EL Transportation Shipment •
L by Common Destination
Carrier
Q Disinterment Date Cemetery Address
•
Q Reinterment Date Cemetery Address
iiig Permit Issued to Registration Number
Name of Funeral Home-j t-t t-Cr- h 0 ci `d o ryee 'r7 C ()O) I 1
>':< Address
ck t . La KL Ltz ci-rt kiy 06tr
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
ILIA
Permission is hereb granted to dispose of the human remains described ove dicated.
Date Issued I (p�( Registrar of Vital Statistics i(Phi .
(signature)
R. District Number 5100 j Place C 1. of G ler,5 Fa ' f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LU Date of Disposition it-1-11 Place of Disposition -ELL or..f..-
(address)
Ili
ftt
IX (section) J,� , (lot number) (grave number)
Name of Sexton or Person in Charge of Premises jl'ny-1 S�hq(t
(please print)
44. Signature kap Title C2�»fj,0�(.. -
(over)
DOH-1555 (02/2004)