Wilcox, Michele �1 )3i( ,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ai64 e/e, /2- G��co>c /L--
Date of Death Age If Veteran of U.S. Armed Forces,
2 e 7/06. gy War or Dates
Place of Death / Hospital, Institution or L
Citylii , 7e. /`Town or Village � 7 k Street Address 6/ /7OS /7 4/
0 Manner of Death ❑Natural Cause Wccident 0 Homicide 0 Suicide ri Undetermined El Pending tki 'I Circumstances Investigation
ut Medical Certifier Name .- ii Ti e
71/j2 0 7'�'( TA6h1..7O/6‹. �_ �D20�/�
Address 5 2 `V/_ i/?✓f *e 67--4-t2 )_ ,.<!S
Death Certificate Filed �� � /� District Number S,�O/ Register Number
City, Town or Village /
❑Burial Date 0 g/23/Z Cemetery or,zmnriyiezi) �n 1�v
;:: ❑Entombment �--�c J1J
Address Qciee, s (my y
Cremation
Date Place Removed
C ❑Removal and/or Held
and/or
Address
to
Hold
0 Date Point of
EX r—i
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home /it,46d� /U 2,i !� � 0// E--)
Address / of ) / i) �,y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ir
til
"' Permission is hereb granted to dispose of the human remains des ibed a ov s i ted.
Date Issued OS' 2-3/06 Registrar of Vital Statistics
(signature)
District Number ,.})60/ Place 7� ,7�, ,"y
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition /13/0c Place of Disposition OftoViPw Gc.,,.,-("<,,r,.. r.
2 (address)
Ili
ta
CC (section) (lot number) (grave number)
0
Ci Name of Sexton or Person in Charge of Premises k;.S Se na w-
z / I (please print)
1L ci Signature tom% � -°s Title Crrm stc. r
(over)
DOH-1555 (02/2004)