Wilkes, Patricia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Middle Last J� Sex
Y+4A t C( A' Ll
Ce;e of ath A e r If Weteran of U.S. Armed Forces,
Q 1 War or Dates
Plac Death n Ir Hospital, Institution or
Cit , Town or Village ` C; Street Address
Mahnir of Death ®Natural Cause Accident 0 Homicide Suicide Und termined Pending
Circumstances Investigation
Medical Certifier Nape n Title
Address
D p C1A �Q I Q
Deat ficate Filed District Number URegister Number
City(Town r Village a PC31 1 S S
Date eff wery or Crematory
❑BurialZ'It
Address
Cremation
FDate C� / Place moved
Removal l 10 and/or Held
— and/or Address
Huj Hold
Date Point of
N[]Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued toRegistration Number
Name of Funeral Home
Address� _
d` .elegy l 72
Name of Funeral Firm Mal&6hg Disposition or to hom
Remains are Shipped, If Other than Above
Address
Permission is he eby anted to dispose of the human remain a cribed bove as ind' ate .
>' Date Issued 2-q A6 Registrar of Vital atistics
I nature)
District Number 1551 Place rL NAw Ynrk 12998
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 5e—?rPlace of Disposition
(address)
(section) (lot nu er) ( rave number)
F Name of Sexto or Pers n in Charge of FR. emises
(please print) r
Signature Title r
DOH-1555 (10/89) p. 1 of 2 VS-61