Fletcher, Debra t
NEW YORK STATE DEPARTMENT OF HEALTH d-I 7,
Vital Records Section Burial - Transit Permit
Name First Middle LastKeil
SexDate of Death t , Age If Ve't an of U.S. ArmedForcesWar or Dates}- Place • Death '�
illg ��� I� � S reet A, Institutions � �
Ci , Town or Villa Street Address
t Man - • Death Natural Cause Accident Homicide Suicide Unde rmmed ending
W Circumstances Investigation
tu Medical Certifier Name „, " n Title4 `rR
cV
Address ri,\ 40„,,,m, ,, ,\,_,,, licp
QDeath Ce• sate Filed isnct Num Rr r
City, f illage i\C AYst2
['Buda Date91 1 Di Cemetery or Crema or�i y
v\a° 1 kri\a\11 1
;['Entombment Ad dres
':;;Cremation W:CKb Wli\I
Date Place emoved
Z❑Removal and/or Held
- and/or Address
F_- Hold
a
d Date Point of
. Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address A.
❑Reinterment Date Cemetery Address
Permit Issued to C i)()A on Regi r N tuber
Name of Funeral Hom Z 4
Address ` `� • ; 4�+'� M 1�1�' . I
>: Name of Funeral Firm king Di position or to
• Remains are Shipped, If Other than Above
;2 Address
tr.
U
IIL
Permission is ereb granted to dispose of the human ains des rib ab ve as indicated.
Date Issued Registrar of Vital Statistics
si ture)
District Number Place V' ,`
B ey VL)
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
ill Date of Disposition 11-a1"t'3 Place of Disposition Z„�c A.., ric43
r,,,,;
(address)
ili
tO
Cr (section) (lot number) (grave number)
cv Name of Sexton or Person in Charge of Premises nst -- 3t�.
(pl se print)
Signature L'' Title CPI meat
(over)
DOH-1555 (02/2004)