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Young, Ella
/qL( NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit °y 1 Name First Middle Last Sex Date of Death / Age If Veteran of U.S.Armed Forces, 3 .?6�aev6 �'a war or Dates _$: Place of Death Hospital, Institution or City,Town or Village u ee4,wm.Q v Street Address 771E S7e9Ain.0 dl)uuse.�:6 g..6 0- -4- Manner of Death EN Natural Cause [Accident [3 Homicide [3 Suicide 0 Undetermined ❑Pending <,� Circumstances Investigation Medical Certifier Name Title +ccISLy,i SocOL6F AID , . Address !66 ,C RC)90 S'T 6,44F.IJ.S �g-c_Ls AJ y /acfd Death Certificate Filed ,Th, District Number Register umber City,Town or Village u c As 6 a i q 5(D5- Date / Ce�metery or Cremator Burial 3/o �d dd t5 vi''ti Vrf:J eal•79125k/uM Address ©Cremation Qc Xe2 �a O (aeek%!g i-t.a y Ai7 /cal�1 Date Place Removed IA IA❑Removal and/or Held and/or Address Hold Date Point of o Transportation Shipment 5 by Common Destination Carrier 0 Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address a4' Permit Issued to / Registration Number Name of Funeral Home �,6,6 f, C/Y �„/C AS-6 O Address A36 tiJ e ; � s . t-�3 ci oily k.ae > Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address OIL Permission is hereby granted to dispose of the human r 'ns descdb= • boy •i _ •. F., 0 Date Issued Registrar I--�1- R �strar of Vital Statistics ,,� - t ture) '- Place I1 C�(-II-N. t9-Q:�-,�L C�-1. District Number jC.e�1 I certify that the remains of the decedent identified above ere disposed of in accordance wi is permit on: f Z Date of Disposition O Place of Disposition 79f N{;1/c jd/ C''_f ,CA,t i4 k tZ t C) ir * (address) 0 (section) (lot number) (grave number) og Name of Sexton or Person in Charge of Premises A-12( (Q--f?A kl 4-- (please print) Signature ' {3 � , 66-----" Title CR OK f - f DOH-1555 (10/89) p. 1 of 2 VS-61