Kirker, Mildred NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Se
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Date of Death �?�(�� Age
¢ If Veteran of U.S. Armed Forces,
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Z Place of Death Hospital Institution or
W City Town or Village u Street Address m u
.. .... , . ... .. . ..:: t -....... . Q .11tiG G i -
L�. ivMnner of Death Undetermined Pending
atural Cause Ac ' ent Homicide Suicide
Circumstances Investigation
............................... .....................................
Medical Certifier Name Title
c:... @. c w.' ..... . ...: ...... ..
Address
Death Certificate Filed District Number Register Number
City,Town or Village
Date Cemetery o Cremator
❑Burial e
__
remation Address
QuE�.tJ3u
Z; Date Place a oved
Olj [] Removal and/or d
H and/or Hold :.... .................... ........ ..... ._::.. ..:
Address
Fn
0......... : ..................................................
CL Date Point of ...................
N ❑Transportation by: Shipment
p; Common Carrier ...... _. ..... . . :::::::... ..
Destination
................................................................................................................................................................................................................................................................................
El Disinterment
Date Cemetery Address
..............................................................................................................................................................................................................................................................................
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
Address
t-: Name of Funeral Firm Making Disposition or to Whom }
g: Remains are Shipped, If Other than Above
..._.._. .......... ......... . . _. ......... __ _ .... ........ _ _ _ .._
:M ....Addres....................................................................................................................................... ................................................................................... .......................
a.
Permission is hereby granted to dispose of the h ifiib retains a ovDate Issued �� Registrar of Vital Statisti 1.�--�!;e7ed
�--
signature)
District Number :��LSr7 _ Place
certify that the remains of the decedent identified above were disposed of i a cordance with this permit on:
W Date of Disposition ��� Place of Disposition l(�.�f�IleC
2 (address)
UJI
Cn
(section) �� (lot number)/ (grave number)
p>> Name of Sexton Person in harge of Pre ' es OE24 7�( � X 4f ;!: �(b!
Z (please print)
W Signatured ;o —' Title /
DOH-1555 (10/89) p. 1 of 2 VS-61