Belgard, Tina i . . i, 11,71
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir t Middle Last Sex
7 it A A. . 0�. g,o --d
Date of Death /� Age �.^ If Veteran of�.S. Armed Forces, „Le
�A - a'1 — 01 4 1 J� War or Dates
}- Place of Death Hospital, Institution or
w City, Town or Village 5c4'd...0-0\_ Street Address F0 4J/p e Ale.
1 Manner of Death-i&atural Cause O Accident O Homicide O Suicide O Undetermined O Pending
lU Circumstances Investigation
W Medical Ce ifier Name /� r ��� Title
0 kr 151i rN 1
dd ess �J
q CanE C.r ch .Fr►,J h tti•,,
Death CertificateeFiled �� District Numbe FG� Register Number
City, Town or Village ��,qy� -�
OBurial Date ' V°' v Ce e ry or Gratory,
El Entombment "g _ 7— /1? I112 0 e,t, Ure_i Y1A re
Addres j
&remation SQ 0 Q.,f/ij,S U ty Ky 2(
Date / Place Removed
Z' O Removal and/or Held
and/or Address
t Hold
fa
O Date Point of
ej O Transportation Shipment
a by Common Destination
Carrier
O Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funer Home SA01- 1_- 7t-L! rukl-offkt ,W 0 04-77
Address:::„ - rp �C�/ .-Name o Funeral Firm"Marring is osito n o o'�IVho m �`�' V
9 p
1 . Remains are Shipped, If Other than Above
2 Address
lU
C1" Permission is hereby granted to dispose of the human r ' s described above as indicated.
Date IssuedO2--di—de/ Registrar of Vital Statistics g� 2`� zt_t� Ca ti(i.i t Q
(signature)
District Number I5 6,3 Place C vtt- i'A 4_ ik.).X- "
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition 3.1-/7 Place of Disposition Pjy Q.L.), &c1 CTeyrrc 4,v
2 (address)/
Ui
w
11 (section) 4(lot number) , (grave number)
0 Q
Name of Sexton Pers in Charge of Premises LA.�i c:.,y t C7ct- X:e
2 (please print)
iii Signature Title C/2ir'ca '"-1 T gYa.4-7.
(over)
DOH-1555 (02/2004)