Osbourne, Blanche NEW YORK STATE DEPARTMENT OF HEALTH E I'x 2
Vital Records Section Burial - Transit Permit
Name First Mop_ Sex c,n� R � La rvt� F
Date Death ,�r�, Age If Veteran of U.S. Armed Forcet„f
oj i .—t O q2 War or Dates n/I
Place of Deat (� Hospital, Institution or e
2 City, Town ogar t, GLIVeakil(642- Street Address L0214 IQ( u r 14 4 P-
aManner of De. k Natural Cause El Accident n Homicide 0 Suicide 0 Undetermined El Pending
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1,11 Medical Certifier Narni A m Title
... Add 'A 1_ it,p_ sf
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U f((€ N� Ic �2-
Death Certifica led ��V� �1it District N Register Number
City, Town or ill4 &I U(( 3?-.
❑Burial Date Ceme ry or Cre atory
❑Entombment Address
Cremation a _ Df v /
/
Date Place Removed
gn Removal and/or Held
and/or Address
1.= Hold
t0
0 Date Point of
Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ,�ii4 '/ � c�'w Registration Number
Name of Funeral Home KdWii� VI !L (A r �VI • I4A'� 6 I —573
2-6 atOtidn 4- • ) Ettical C k W 1D-S2-2--
Name of Funeral Firm Making Disposition or to Whom
l= Remains are Shipped, If Other than Above
„ Address
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P` Permission is he eb granted to dispose of the human remain- -• -d a.,ov- indicated.
Date Issued 6 (3 0rr-- Registrar of Vital Statistics ��_� �)';
�P J
(signature)
District Number slag- Place VV1 (( U(f Cam'
t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
lu Date of Disposition (...A4 d (, Place of Disposition (?„z i- ,,,, ,,, ,
2 (address)
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tin
1r (section) _. (lot number) (grave number)
Name of Sexton person in„Charge of Premises =^ y`
Z (please print)
Signature ILI "kil.A /�r� Title f l r°'^^\_4r''�
(over)
DOH-1555 (02/2004)