Radliff, Danielle NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section 4 Burial - Transit Permit
iiiii Name F-itst I ) Mjddle st Sex
o Lei,C (1€ ply-vw-N J Zo(ii c 11) ✓GBH Ci
Date of Death Age If Veteran of U.S. Armed Forces,
J a✓' I k( ZOO 6 ( War or Dates
Place of Death r` �I J` Hospital, Institution or,_ . / (ity Town or Village CI V 1 Street Address CAI(Ws J f r
nner of Death
1 Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Iflicc. i�L S c Kv fc kce. fr47 D
r�/� Address
V_/ I I70i V%y 01
iiiI Death Certificate Filed ''/ District Number Register Number
, Town or Village C9 1,v�J j. (o G( 27
Date Cemetery ocrematory
❑Burial J u i-, 2 Lf I LOOC c.,.,c �t,.✓ ( v7,7 t,. .-N vL,
Address
l Cremation2i2.e,,,s&,�:y c S1 V
Date / Place Removed
❑Removal and/or Held
••• and/or Address
0 Hold
Q Date Point of
Q Transportation Shipment
3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
lili.„ Permit Issued to / Registration Number
ii
`' Name of Funeral Home C cn— I (, Lv) Z4"Y
Address-)
€..`:�' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
M
Pii Permission is hereby granted to dispose of the human remains descr��d`mac/
aabove nd- .
giiiiii
ii! /Date Issued O/ Z3/OL Registrar of Vital Statistics (signature) /
IN
iiiiiiiii District Number Sto U 1 Place (v )7 01 C' 1 C0J (� I bi 0
f::
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition/-2 5-C C Place of Disposition 4-;sir::l'j It(c,r C Z::::, -i" ?` . 1.0 .-
2 (address)
i4J
(/)
LE ti (section) Qpt number) (grave number)
fl Name of Sexton or Person in Charge of Premises GQ,LC. '- �4/V 7
Z '2 (please print)
t J Signature _, .e Title CC' 6,444-I'G'',r L
(over)
DOH-1555 (9/98)