Beaty, Janet r A.'-' '-..,J. r 1L .to'ad' Y!!•1 FIAJVI . irs omputu 7 iv TL:?La.70."ti,'#'t!.0 N. L
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs Middle Last,/ ' S /
Date of Death Age j If Veteran of S. Armed Forces,
7 — /ef - __-- L., I War or Dates Ai-6
1.- Place of Death ,�� Hospital, Institution or
ZCity,Town or Village 7'lf�'.> e %�+6d�.c.o , Street Address G --
ci Manner of Death[Natural Cause 0 Acc fl ident Homicide L Suicide [l Undetermined i- Pending
ILI ' Circumstances investigation
Medical Certifier Name Title
0 ' /
Address j
Death Certificate Filed d /J/ , ! District Number __.. ! Register Number
City,Town or Village ,�,. �,& �e'-`ilac '^•-� / ✓S
❑Burial ' Date Ceme or Crematory h
Gam /f _ _1 -.� ~Pi vC4-, ( / ,,-,„4 -4
[]Entombment Address:
Cremation l 6,,'6 5d6‘- /Z 1 Jv
Date / I'Place Removed
Z❑Removal i and/or Held
and/or Address
F` Hold
Chi T— -- _.� —
O Date I Point of — ---
aL. Transportation Shipment
0 by Common Destination
Carrier
Date Cemetery Address
':E Disinterment i
Q Reinterment
Date I Cemetery Address
Permit Issued to �---- i , Registration Number
Name of Funeral Home lv',/e'C>:c ,,et „f ,r;,f°v�y �
Address / •
`i /
//� 7'G%'C;L/cf :57 /!4- .4-- A- ,62 `
Name of/Funeral Firm Malting Disposition or to Who
Remains are Shipped, It Other than Above
Address —
CC
'd` Permission is hereby granted to dispose of the human r4trains described above as indicated.
Date Issued 7/% / Registrar of Vital Statistics -I- 2 ,L7 c J/'_-
N-.__„_ (signature)
District Number / Place / &� ,, G .� 1 i r1
I certify that the remains of the decedent identified abbe were disposed of in accordance with this permit on:
W Date of Disposition / 2/i7_ �e Place of Disposition Pi . U cre,yn j^,
Wjaddre si
ft
f (section) — (1 t numbed Greve number)
D Name of Sexton P rson in Charge of Premises w I i 4n 04.-N?fet�
Z (ofeetse print)
ill Signature Title G re-yrt l,•- a
(over)
DOH-1555 (02/2004)