Ball, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
LL✓1 ZA Z C�v ZALL-- - ..
Date of Death Age If Veteran of U.S. Armed Forces,
015_ War or Dates —
I- Place of Death Hospital, Institution or
W City, Town or Village Ge_A, ,' i1-1-l� Street Address 1- l 2S� 5\ .Za. \ kR
0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
U1 Circumstances Investigation
W Medical Certifier Name Title
0 AmV Sur-tNSvN ‘R('ft
Address
t3 PALmerz A-vr CoR►NTi- )J`t 1 a-3,)
Death��ificate Filed District Number Register Number
City wry'or Village 6-(2A J tiL 5 7 S(. i 9
OBurial Date t /
CVemetery or Crematory
['Entombment Address
[,Cremation C�v4,m_(;W._ V.--c:i a3L c tiS. ,:ocL..`-t �`i
Date Place Removed
❑Removal and/or Held
and/or
Address
'I
Hold
0 Date Point of
;0 Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Si Permit Issued to Registration Number
Name of Funeral Home D Cr-::,` M o E is FvN c_Q 4L- \-cryn L= 00--k4i7
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
lltt
CL
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0 q I,I Id.o r 1 Registrar of Vital Statistics L.-v .t -ztY\culRiO
(signature)
District Number 5-7S10 Place Tow1J D F GRANut-i.x
i
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition y1121 I7 Place of Disposition Zt V i4-, erThef oti,.%,
2 (address)
ILI
tft
it (section) Al (lot numbe (grave number)
Ci Name of Sexton or Person in Charge of Premises
Ili r,k1v.er pi to t-
z ( ease print)
.4::,::::„.„, Signature 6Title (5i411P tom'
(over)
DOH-1555 (02/2004)