Frank, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH ` 44 t /p
Vital Records Section Burial - Transi `Permit
Name First n Middle - t Six
m Date of A * If Veteran of•U.S.Armed Forces,
r OJ 3 7 War or Dates ,
°''; Place of Deaf Hospital, Institution or
City,Town or Village //CO rV 6 f RD�- Street Address HOS 4 S (Ga1.i dt;b-TQ Al
' - Manner of Death INatural Cause ❑Accident D Homicide D Suicide' D Undetermined 0 Pending
Circumstance Investigation
Medical Certifier Name ..�,- Title
' / 640-,0 7e• /4)6-t--1)A"Z&... /%1V)
3 Address J-
/6/1 to ail'EA s 7 J /ee1�,.),o i O019" AY 6 3
Death Certificate Filed District Number Register N
�- ' City,Town or Vill ! eb ti 19 t 4®/- / m562
==ElBudal Date Cemeteryw Crematory
DEntombrnent
Address
Cremation6? i c2t.,-/9--4 ,- P.6 (2,6 y
Date Place Removed Y!
rRemoval , and/or Held
and/or Address
Hold
Date Point of
D Transportation Shipment
by Common Destination
tl€<f< Carrier
•
Pi 0 Disinterment Date Cemetery Address
o Q Reinterment
Date Cemetery Address
'iE
= Permit Issued to ;-' Registration Number
nf, Name of Funeral Home 40,<.t —/c- !)` �ii/C__ /[ ,32S--
'` Address j '6 / /9:4"K Ai 6fe&kJ e-t_f' 4? o /
1, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
>:::: Permission is hereby granted to dispose of the human gins described above as indicated.
06 Date Issued - 4- j/3 Registrar of Vital Stabs " Jj .. &-&-e---- ---
gig
. T �
r J (signature)
District Number o o PlaceAla_ f�- T
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition )-i&ri3 Place of Disposition • 7+04uw t�r {orh,,,,
(address)
(section) IX (lot number) (grave number)
1 Name of Sexton or Person' Charge of Pr ises s4 c S rt
(pl ice)
K, Signature 1-.- ��� Title C{Z£f7 Pit t
. «YY (over)
•
DOH-1555 (02/2004)