Graves, Helen e
NEW YORK STATE DEPARTMENT OF HEALTH ° . 3
Vital Records Section Burial - Transit Permit 1113
Name First Middle Last Sex
e\erk
Date of Death Age If Veteran of U.S.Armed Forces,
\ )b.0.1 9.D0 ... _ : (.09 War or Dates
Z Place o ath Hospital, Institution or
Lo City, ow r Village - ,, , I Street Address iO3'7 7 i2} 4
Mann of Death IIIIN Cause Accident Homicide Suicide Undetermined ❑ Pending
Circumstances Investigation
iv Medical Certifier Name Title
rt I1 qci ..:.eie nrt. .. ,_ M... ... ....., .::._::....... ... .. ....
Address
Death rtificate Filed " District Number Register Number
City, ow or Village Gar�i -{� ,5'15L a9
Date Cemetery or Crematory
❑Burial f k 1 21)0(p i€LO, Cfer•nc,ibi
Address
14 Cremation
!1 `-1.5 brc
z Date 1 Place Removed
O ❑ Removal and/or Held
i- and/or Hold
Address
N
o.. Date Point of
cA; 0 Transportation by Shipment
0 Common Carrier
Destination
❑ Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to rr h Registration Number
Name of Funeral Firm a\, ,,,Y .:::.i' nefo_Q \6m- c n3 l
Address ..:
y e 0,\\\ce,(y.S 6+ li3\k e.ina_\\ N-1 (2 '3 Z
} irm— Name of Funeral F Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
Address
III
b-::
....................................................................................................................................................................................................................................................................................
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )1l J 3 �ZDD�P Registrar of Vital Statistics . ;
ignature) ' 11
District Number 515(.0 Place —17bC)r- O-c 6Iar*A III
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition tt"‘3" t. Place of Disposition TintV.t.. (fens wro t)v»..
iii
2 (address)
tt!
M (section) (lot number) (grave number)
0
Ca Name of Sexton or Person in Charge of Premises - I,P. s .c.,n le'
/! (please print)til C r
Signature (, Title C
DOH-1555 (10/89) p. 1 of 2 VS-61