Knickerbocker, Ellen L 11 753
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section -- Burial - Transit Permit
Name First — Middle Cast Sex
L - 11 -.,N h K . cdrb Keg t=
Date of Death / Age If Veteran of U.S. Armed Forces,
It /? c, ( a o`V- (9 War or Dates
I •f Death Hospital, Institution or
.wn or Village :.-4.4 5 r..a Street Address r z 9
-Manner of Death Q Natural Ca e 0 ccid t Homicide E1Suicide El U446termined IIIPending
W Circumstances Investigation
W Medical Certifier Name Pecli:1-6,(
Title
Address 713
De Certificate Filed District-Number Register Number
wn or Village r r4 p2_,_- 555
.Burial Date / Cemetery orcrematory
I I/ )3 olail5 ,.i etre-, C--&4-1-tod,
is❑Entombment Address
XCremation �j�,A6 z"Ste'``''. Cv
Date �,J Place Removed
Z n Removal and/or Held
2 and/or
�; Address
Hold
fa
O Date Point of
ft❑Transportation Shipment
eh by Common Destination
• Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Wi Permit Issued to �^ Registration Number
Name of Funeral Hom „S"►.-)-c I t, A,-r.•C )4d-+�, --- o o``�'br
Address .7 f ,_ N r 1 -- cZ�
Xe.ra,.-r� ✓C/ C
qiiii Name of Funeral Firm Making Disposition or to Whom
1..i.: Remains are Shipped, If Other than Above
2 Address
Cr
III
tl
N: Permission is hereby granted to dispose of the human remains de ribed above as indicated.
Date Issued 1 Va3/// Registrar of Vital Statistics tt ( H --
(signature)
District Number Lit-S'v j Place crr� ) r, .
I~- I certify that the remains of the decedent identified aAS.rove wer disposed of in accordance with this permit on:
til Date of Disposition i/It3'kg Place of Disposition ,,\1...I 4,117%
(address)
ti
U)
CC (section) /�(lot number (grave number)
Q
el Name of Sexton or Person in Charge of Premises (LOP 61 ► 64
a
(please print)
:: Signature . Title at-f'"1l1dd-
(over)
DOH-1555 (02/2004)