Kingsley, Grace NEW YORK STATE DEPARTMENT OF HEALTH # s31
Vital Records Section i Burial - Transit Permit
Name First 71Middle Last Sex
race -1 s e 6-4 o1GkP C .V F.
Date of Death Age If Veteran of U.S.Armed For
= q/y/2D/3 6 2 War or Dates
ePlace Hospital, Institution or
C" To)or Village �i l 3bu Street Address _S L'I Oq ed
Manner of Death Natural Case Accident Homicide Suicide Undermined El Pending
ll#f Circumstances Investigation_
iii Medical Certifier Name, Title
A/'c 7L1;C, _c1, / '1t c 11/4
Address
/‘
6, 11/11 Death rtificate Filed ct/Number Regist r umber
City, or Village P ,h5 /Any/ L C� I
=< DBurial Date q 1 Cemetery Crematory a
ntombment Address •r /Iri 6'�
l remation
...iDate Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
tti 0 Transportation Shipment
by Common Destination
Carrier
'' El Disinterment Date Cemetery Address
� Date Cemetery Address
Q Renterment
liN
iT,ii,;:i: Permit Issued to Registration Number
::: Name of Funeral Home Haynccrd •Zaker Fu.necc( 14O( 01110
Address 11 Lai-'GIVE-He- Si r cc+) Q ue e n sb u r y , New Var. k ) $o y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:.. Address
>- as i
Permission is hereb granted to dispose of the human remains described ab cndicated.
l! Date Issued I it Registrar of Vital Statistics am l _
>r3 (signature)
iDistrict Number cb Place d wV 0 r ( __.,c21-,
I certify that the remains of the decedent identified above were disposed of in accord with is permit on:
N Date of Disposition `l I(,1l3 Place of Disposition FN,UI Cts- to x _
(address)
Ui
CC (section) A (lot number) (grave number)
aName of Sexton or Person in ge of Premises '�op�,�, D 1 b
Z (phase )
TE Signature Title Ci2 t(i ICrt
(over)
DOH-1555 (02/2004)