Ramsey, Pauline NEW YORK STATE DEPARTMENT OF HEALTH '�
Vital Records Section i - Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S.Armed Forcds,
OD., I la. I ao a c 1 War or Dates tJ )
Z Place of Death • Hospital, Institution or
Lii City,Town or Village �te..,Sbv rN-NiStreet Address T-o___ S c.r ;"O
Manner of Death ® Natural Cause El Accident n Homicide ❑ Suicide ❑ Undetermined n Pending
W Circumstances Investigation
LU Medical Certifier Name Title M
Address C p Q:..:
li :: .LcS S . SC-A �wGc--� . N (as aV
Death Certificate Filed b trio Number Re aster Number
• City,Town or Village blve-eYsS`perr' % �U , ----'- A
Date ) l Cemetery or Crematory
0 Burial ) to O 1,a i ; •r.e_ \J ,Lw cr-e..._wt.c,--1-c.,`�
IlCremation Address•
z Date Place Removed
O ❑ Removal and/or Held
I- and/or Hold .
Address
cn
it Date.::::.:.... ..:.: .... . .::. Point of
v ['Transportation by Shipment
0 Common Carrier ...:.:::.
Destination ,
El Disinterment
Date Cemetery Address
.. ...... ... ..... . . . .. . ... . ... ..
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm \fin S M.O «, t r urf-\ lAp DL Cho L‘.L
Address C` n 1
ks. Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, It Other than Above
Ir. Address
W
Permission is hereby granted to dispose of the h m remainsdescri d above as indicated.
52�
Date lssuedgZ� ( 'LiI� et ,
l � Registrar of Vital Statistics /)�_...,,,
--; — (signature)
District NumberC9 S Place ! (;:i_g_...fN a �^/ (:::2)u_e9 ,
I certify that the remains of the decedent identified above were disposed of in accordant with this p rmit on:
I-
w< Date of Disposition �� I7 tZd 12 Place of Disposition Fr. V t > C 0rq. ,
E (address)
w
C (section) (lot number) (grave number)
O:
p< Name of Sexton or Pe son in Char e of Premises A0-174s-.- e��
Z (please print) j
tu Signature 4 .-, Title CeetilAk14,
DOH-1555 (10/89) p. 1 of 2 VS-61