Tyrer, Ophelia • II1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
:.:.::•.:::::::::. ,:p:'..EL...i.A::......._...............:._......::L..A.R9ES........... :::.:::.:......:...:.::.::::..tc .:::. ::........._................... ................fem.
>' Date of Death Age If Veteran of U.S.Armed Forces,
War or Dates
lace of Death Hospital, Institution or
j14--ity,Town i.,, Village Street Address
.LAKE. oR..GE,......:.. :::....: . 369.....t3i.00.Q'.. ...:?ot\t.. ...::....K.9, ..... ....................... ....
WManner of Death Natural Cause Accident Homicide Suicide Uetermrted ri Pending
1-1 Circumstances Investigation
ltt Medical Certifier Name Title
...::::. ......................:...........
Address . 'EAI.....:::................ m ..... ......
in
3.'.7(0..7.... f\... ..... T1..)....wil .R. s.S3.u.+ -,.°1ul. ..... ..R ?�
... .l.
im Death Certificate Filed District Number Register Number
-Gitp,Towner Village LAR F. g-n=.o R C,s � SoS/ 1
Date Gerrret ry ul Crematory
❑Burial
e A 1 ., .,. :.:.. .Q. ........ P ... .. .. ......v...E ... . ..,.Q.R....... .......... ................
Of remation A dress
.:.. .....Q. .AK,f,g........ ...)..... ...u.. t4S.Q.tL... .. ... `{) ........... RK,.
Z Date Place Remove )
0 12 Removal and/or Held
Address
Cl)
n. Date Point of ..,
0 Transportation by Shipment
p< Common Carrier •..::......:.::................:..:.....:
Destination
............................................................................................................................................................................................................................................................................
Disinterment Date Cemetery Address
.
❑ Reinterment
Date Cemetery Address
iin Permit Issued to Registration Number
Name of Funeral Firm..... a NtI_AL . E..;:t a.c.1 .............: : .. : .... :.01. 10.:::.:
Address
.. ...::... ::....9..0......1Y t 3 CAL. .. 'f.... .LAK . Gsoi C Ist,g,t<i-ln 0La ::...I a-8.-.`Ls
s:z Name of Funeral Firm Making Disposition or to Whom..:
j Remains are Shipped, If Other than Above
........ .....:....:........:.................:...........................:.......:.................. . ..::..::.......... .........::.:: ...
Address
Al
Permission is hereby granted to dispose of the human remains descri ed above as indicated.
Date Issued 1 — 1 -,„9.00 c Registrar of Vital Statistics i� J�
r
iini
District Number L.5-6 S/ Place LAWS. CrEnRGF t 1l e.lZ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1' 1. — U ke Place of Disposition 1" ;n e v Ir C t 6 vr•S"\—G1-r vn-
gi (address)
W
cn
(section) (lot number) (grave number)
Z' Name of Sexton or Person in Charge of Premises h r,3 Stn Rl tt
(please print)
Signature L , ��o Title Crrvt\4A-Q.r
DOH-1555 (10/89) p. 1 of 2 VS-61