Goldstein, Ruth 3
NEW YORK STATE DEPARTMENT OF HEALTH A 11(0
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
t/TJ� A AlA> 6-OG M S,: i Al A . .,
Date of Death � � , Ag If Veteran of U.S. Armed Forces,
0c6 —/O v Q/5 War or Dates N/11
}- Place of Death Hospital, Institution or
zeity.zawn or Village A/O/ %;
IN L61 Street Address A H 6 �c . (/114. , 1411/zf C TX
ri Manner of Death r71
kin Natural Cause El Accident 0 Homicide 0 Suicide Undetermined ri Pending
til Circumstances Investigation
W Medical Certifier Name Title
0 Di/3o14N HA N P--C-
Address
/KS 0CD ,cl/C,!IA1L'7 fLj) ,tAke A. (.1✓' l ti Y /Z9VC
Death Certificate Filed District Nupnber Register Number
City, Ts ti orui+kcge A10M 1I ai2A y 560
['Burial Date O S '1n Cemetery or Crematory
C�/.� "VC: 1//kJ UZ.6/4"/A76) —y
❑Entombment Address
0Cremation ! /Q �& /l . G?r.fg,�'. 6uft.y A4/,/ /d.$C
Date Place Ren4oved
�❑Removal and/or Held
and/or Address
t` Hold
41
o Date Point of
filli 0 Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re istration Number
Name of Funeral Home Ai/d &A ix,/G O f 0 7 r
Address
..3/O _,eiz 4iU, L AV'. LA/ RAu6 ,Ayi0c_q y /
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
2 Address
tip
lit
P.`. Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued iZ-/3 Registrar of Vital Statistics C�tz<(6r',/2 tc�l��
(signature)
District Number ,/. 60 Place %O di= Al01 K £L&
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tU Date of Disposition $1 t3113 Place of Disposition ,4?„,,, t, , C dr.,...
(address)
iAl
#1
CC (section) of nuipb ) (grave number)
Name of Sexton or Person in Charge of remises )1.*j L. . 50"J/0-
Z (please print)
W.
Signature �— Title CZ260 ,
(over)
DOH-1555 (02/2004)