Otto, Kitty Washock 5186086 rsi l p.c
— # -7°7
NEW YORK STATE DEPARTMENT OF HEALTH
Vitt Records Section Burial - Transit Permit
Name First ;/, f Middle Last + t 0 I F.0 Ir?Q. C.(
Date of Death Age If Veteran of U.S.Armed Forces,
ii 1(f Z AD,t3 /b 5 _ Wad'or Dates AJa
` Place of Death jt / f ,,r.� Hospital, Institution or
City, Town.or Village C� b t MQf Street Address J /,4Y,&//cc_i
` Manner of Deathi73 Natural Cause []Accident 0 Homicide 0 Suicide 0 Undetermined Ei Pending
at Circumstances Investigation
ILI Medical Certifier Name .�.�- 4 l Q Z T t • ��j i aL Titezit_le
`F Address /FY it f rrtl U
. Death Certificate Filed f' —�-- District Number ' Register Number/
City,Town or Village C( 6 t-� 1 1 i/b a &(f
❑Burial Date 1 Cemetery or Crematory
<=[]Entombment I t j'5/21a LS Yriti V/e .3 ()O't°."774
--= Address /� J
Cremation t Jike_e_ 2.. , AO 44JJJ
Date Place Removed
❑Removal
J and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Li Disinterment Date Cemetery Addrcss
`'0 Reinterment Date Cemetery Address
<' Permit Issued to 1 Registration Number
Name of Funeral Home .' . 1 r /t l., �A I. _'1 Aloti.—. i di-0 d
Address
Name of uneral Firm Making Disposition or to Who
Remains are Shipped, If Other than Above '
Address
w
n. Permission Is eb granted to dispose of the human ns a i a as in mated_
>' Date issued d t Registrar of Vital Statistics
(signature)
District Number /() 7 Place ikli
certify that the remains of the decedent identified above were disposed of in accordance with this permit on;
rrij Date of Disposition II- 1(,"(3 Place of Disposition ZNGr) C rrwc f cnti...
"€gs (address)
(seen) qot n bar) (grave number)
Name of Sexton or Person inCharge of Premises , f> hill
riji (ilea P 0
Signature Title Clt O/}i`d
(over)
DOH-1555 (02/2004)