Keller, Kyrie 4 0 ��
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name Firs Middle 1 Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
‘O'�512k War or Dates
ej.ac,p of Death t r-- \" Hospital, Institution or 1 v — i l
i .
tioown or Village G\. tG��S�- ti \ Street Address `� QC h � -`` 4
Manner of Death�Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
QMedical Certifier Name �\`\ rc) \� Title M''
Address 03 (iCk.v cA gr.. .5 i�, ,5 ,\\
Death Certificate Filed L1'LC`5G �S District Number �01 Register Number ' E..it Town or Village
❑Burial Date ,b' ci)'2\ Cemetery or Crematory �,
NX•14..-\1‘\ estz-vm
❑Entombment% Qxc�.
Address "� e� Sx� `�y n
Cremation
Date Place Removed
� Removal and/or Held
O and/or Address
E Hold
CO Date Point of
Transportation Shipment
tali by Common Destination
O Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
Name of Funeral Home �cwa - �^- \, VA C) \C
Address C t` )5• `"\ c1\-X,: '\v\\ \2 `Q
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
$ Address
IX
W
°' Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued 10I)ViZ i Registrar of Vital Statistics
(sig re)
District Number ,rXDO\ Place Glens 'la b 1 /Vlj
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
0 Place of Disposition �c�l.. "--11,-4-.....
Date of Disposition I I I$I Zi
,2 (address)
W
rt (section) t number) (grave number)
Sexton4
O or Person in Char of Premises 4, _StA4 it
Q Name of (pteasd print)
W Signature Title <a `47-
(over)
DOH-1555 (02/2004)
1 234
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#