Bachelet, Gladys r p
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last, Sex
`h .y.. .. ...:........:..:..: .:.:. ......:. A e/.. ........ .........
.......... . . ....::.
c-� F�OW���
...................
ate of Death Age If Veteran of U.S.Armed Forces,
9,z
War or Dates 0
. ... . ... .:.. ...... . ...............
Place o Death Hospital Institution or
S�j Street Address
:W City own r Village hO 0 �ol'...:��:.:�.7....:.:..:..
.: ..:. ..
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
... . .. ....................................... .:
Circumstances Investigation
Medical Certifier e Title
...._ .........................................................:::.......... . ..
Address
..... .............:..:.......
De...................................
th �� � ificate Fileci District Number Register Number
City owner Village
Date Ce tery or Crematory
0 Burial
s= I 93
... .... .......
. ...........:.....:��:.. �:•ve c9%e........ .. ............... �-. p.THY...... . ..::.
[Cremation Address
.... _.
Z Date Place Removed
O ❑ Removal and/or Held
t" and/or Hold ...:::..:::.:.::...:.: . .::.........:
Address ............. _ ........::: .. .. .:::::: _ ...................................
O...:.:..........................:...............:.:. .. . ...::::: . ......:.. . _ :::.: ......................
CL Date Point of
N []Transportation by: Shipment
0I Common Carrier .:...........
Destination
.............:........ ........::::::::.....:. ................... ....... _ .......
.......... ..................
0 Disinterment
Date Cemetery Address
...... .::...... . ..... .................
0 Reinterment
Date _.. Cemete Address. _. ....
Permit Issued to Registration Number
Name of Funeral Firm 2—C OVX1 r ��� ��,�c, ,q/ /�G+�ic
... _ _ ........... ...... _.........
Address
.. .: .....
... ................::...... . ..... . ......... ... . ..
Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, If Other than Above
................ _..... _ ......... _ __ _ _ ....... _..._..
.......................................................................................................................................................................................................................................................
Address
t
....................................................................................................................................................................................................................................................................................
Permission is hereby granted to dispose of the hi m3n raTains described above as indicated.
»' Date Issued s�- i s 93 Registrar of Vital Statistics
/ (signature))"
District Number ) L 3 Place �P�t�i�BJ►t� f, r-
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z,
H Date of Disposition Place of Disposition �,�� ��� /�/i,/�aW
(address)
LLJ<
it (section) (lot number) (grave number)
° g '67 xe&-/�ZF-�ATi -,111
p Name of Sexton o Person in Charge of Pre ises
Z' (please print) -�
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61