Deyoe, Leafy NEW YORK STATE DEPARTMENT OF HEALTH �(4 I
Vital Records Section Burial - Transit Permit
Name Firs; Middle Last i Sex
/ e Ll P .itCA - ��t/o M,/�
Date of ath 7 " Age If Veteran oU.S�Armed Forces,
e-c I k ,, �v o 6 I ), War or Dates
E...; Place th Hospital, Institution or
Z C. 0,Town Village Co 1,4,... Street Address 116 La 4- 1.
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j M'arrrrDeath Natal Cause ^Accident Homicide Suicide — Undetermined —Pending
—Circumstances — Investigation
W Medical Certifier Name /� Title
Ci ( ic,kaeL & 1I ,/t'1 -I) -
Address 3 Pa K A-ue.A-c_._ r, tJt�. , MT / gA-
Death ate Filed District Number ' Register Number
City, Trown Village J i TI F .. ,_ Li S S S
Date
Ce tery or Crematory
Burial „Dec __ I `( (I Do L -.�_
;fie ,f.�c �/cM ti 4 t, -
Address
eNI Cremation P 7
Date J / Place Removed
O n Removal and/or Held
- and/or Address
N Hold
Q Date Point of
O.
_Transportation Shipment
Es by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ----- - i Registration Number
Name of Funeral Home e.vr 5,1,—crier» C- � � 1 Uv `fs
Address -- I' /�
I erM4— A-kic I,',lg '�.. /qq
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Name of Funeral Firm Making Disposition or to Whom !
Remains are Shipped, If Other than Above
aAddress
LU
E1
Permission is hereby granted to dispose of the human ' s described abov s indicated.
Date Issued ) /I 1 /o 6, Registrar of Vital Statisti s c .. i- l 1..A____,-v
/� sig ture) �C
District Number 9 SS Place ! 'I /t-yam'-- I ' ''
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on
I-
WDate of Disposition i��ti Jo Place of Disposition -Pi As ti4.,..,) C...rezrr ct f or t„vIN
(address)
L1J
CC (section) // ,(lot number) (grave number)
Name of Sexton or Person in Charge of Premises Ch r, s 01,1rtP1T
Z �yy` (please print)
W Signature iiu.,� . �",,a -' Title Ct to{-cr
DOH-1555 (10/89) p. 1 of 2 VS-61