Morehouse, Grace NEW YORK STATE DEPARTMENT OF HEALTH 3 `
Vital Records Section ` ` Burial - Transit Permit
Name First Middle Last Sex
C `-IN\c*_F N,rxiS E TEMittE
Date of Death Age If Veteran of U.S. Armed Forces,
q9 81 War or Dates N A
}. Place of Deett Hospital, Institution or
5 City,hewn er Village GcLEND.; AL,L,S Street Address (�d,E,Ijs VALLS \-\-0S41—T1\L
0 Manner of Death ,Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
tii Circumstances Investigation
la Medical Certifier Name Title
Address
'.--,a' Gry (� Fps LLS g-oi
Death Certificate Filed District Number Register Number
City, i-er Village `--, VA LL s .c(n 01 AZ<
❑Burial Date Crematory
/'�,
DEntombment — �`� J a ) cg-Oo( 1 tJ E� \)I Ei,�D (A--ESY`c\MR-1 l l Vv\.
Address U
►e remation \ ('Ru AkiR c• u.E.ENsc&.l e,`Cl l d g O
Date Pla a Removed
❑Removal and/or Held
and/or Address
i Hold
Cl)i
O Date Point of
ti❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home $- p N CR ILL -m c) \N.C• 0 l 1 lO
Address
R 0 `'\\(`not cki, \ Si, LAKE; G c GE) `1'1 �t a-% `�s
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
Lu
` Permission ie harohV nranted to dispose of the human remains descri ed a ve s in d.
Date Issue° ,j /,2 4 bt✓ry Registrar of Vital Statistics /
, signature)
District Number Place �1,-1 A 75 ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tLI Date of Disposition f t 1/ h Place of Disposition P,n t,;, ,w C .. n• . r , h
2 (address)
141
Ul
C (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C k r` S C-'.inc ti
(please print)
Signature L - vu 4-1A\.Z1 — Title Cr e^^y'%'4.
(over)
DOH-1555 (02/2004)