Leclerc, Shirley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section • Burial - Transit Permit
4.
Name�J4/Fiirrst p Noddle Last Sex
Date of De thi lG Age R . If Veteran of U.S. ArmedForces,c, F
Ob/a2f02OQ6 gFO War or Dates /d
Place of Death Hospital, Institution or
�: City, Town or Villa e
y 9 6/�`�,�j�/WA/4 Street Address �/�jj,S�G�f,[f'
Manner of Death pf Natural Cause Accident Homicide Suicide Undetermined Pending
ram' Circumstances Investigation
Medical Certifier Name Title
Ro66->2 7 6/SS , /1 a
Address
v.26 6l5cv /7%W /,,.20l
Death Certificate Filed District Number Register Number
City, Town or Village6/(7 fj'//5, ..5-e /
0 Burial Date ` Ce eter or Crematory ,c /
❑Entombment �' �o0 6 //% 1� /&- CleG'�/ 79 l
Address
"Cremation
Date Place Removed
.' Removal and/or HeldF and/or Address
Hold
*. Date Point of
Transportation Shipment
: by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home OfjrSoa e6 A/4j ici. 697 00
Address
7 511 /9,t/ ,w / CO/e//tc779 / //k-a.2
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
h- . Address
g
Permission is hereby granted to dispose of the huma emains describe above as' dic=ted.
Date Issued O64S/006 Registrar of Vital Statistics 02, ,
r
q sig ature)
District Number S66/ Place
certify that the remain 3t.tfaeiecedent identified above were disposed of in accordan with this permit on:
Date of Disposition's 2614 Place of Disposition pJ A(E tI E t) C2 . g-Av )6Zi 4)1
6,-S*0
(address)
:: (section) � (lot num r) (grave number)
Name of Sexton or Person in Charge of Premises G4iL1 +' ' �'RYI Si.)r (please print)
i-. Signature -Qt et-A Title e'R 8-e''i W iC) ( ,
(over)
DOH-1555 (02/2004)