Hutchinson, Jane NEW YORK STATE DEPARTMENT OF HEALTH , A 41 W
Vital Records Section Burial - Transit Permit
Name First Middle L st
U n� 0 (,-c -�1 0 ..r
Date of Df
ath / A If Veteran of U.S. Armed Forces,
I I £ g War or Dates
.N Place of Death Hospital, Institution or
City, Town or Village Street Address
iii• Manner of Death'Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
iti Circumstances Investigation
0
Medical Certifier Name Title --�
(2itr Il14, f\oet P I
Address
DeeGe icate Filed DistTeel.? Re �r Number
Citown o�Village �L - j� p
❑Bu iat Date Cemetery or Crematory
❑Entombment Address
❑Cremation
Date Place Removed
❑Removal and/or Held
2 and/or Address
I= Hold
11)
0 Date Point of
ft❑Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to f� 1�, Registration Number
Name of Funeral Home f7RIPF -P V 5Nt ZO� Ie� f/r- 01130
Address
II 14 .4,tft St- 6ve•I kt fin- (1 V
Name of Funeral Firm Making Disposition or to Whorrl
10 . Remains are Shipped, If Other than Above
'„ Address
it
tt Permission is hereby granted to dispose of the human mains described above as indicated.
gi Date Issued �1 ( � / 0tARegistrar of Vital Statistics r c . a.&,t.,
(signature)
Riiii District Number Slog--) Place r ( Q
I certify that the remains of the decedent identified above were disposed of in acco an a with this permit on:
tit• Date of Disposition T Ili Place of Disposition _fZ ¢,r„! 6: faA
(address)
L
ta r
III (section) (lot/`mb1er)n c (grave number)
flName of Sexton or Perso in Charge o Premises r1h�1�
2 f. (please pri
UE Signature Title i ?u/L
(over)
DOH-1555 (02/2004)