Bolton, Simone I \ 46
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section '�" BurialTransit Permit
Name First i YYl 0n e Middle Last 1Jo»� Sex r
j Date of Death Age0l 1 If Veteran of U.S.Armed Forces, f
4 > � ' �6 1 1 - `"( I War or Dates NI A-
Place of Death Hospital, Institution or tC/ PwY\.v3] d A-v_e___
Z City, Town or Village & 'L�ASN- 0 v `'{ Street Address
1nManner of Death Natural Cause 0 Accident f Homicide 0 Suicide Undetermined n Pending
LLt Circumstances Investigation
Ili Medical Certifier Name Title
P Wt llcc r r�eS MO
Address
I lQ` Carus 26 CQLnc bar y`�� 'N`/
Death Certificate Filed I Distrt€tNumber Register Number
City,Town or Village bLD eenC b..1 1 \`J (q ( 0
_< ❑Burial Date - Cemetery or Crematory
'61Z Pre. \i , ev3 Crna4
❑Entombment I '
Address
:_ aCremation 0,30 .�� R v 00-Ck (Doc m\ 1 z260`-1
Date Place Remm4d
Removal and/or Held
—and/or I Address
P"-' Hold
t#r
Date Point of
CL n Transportation Shipment
by Common Destination
Carrier
'< Disinterment Date Cemetery Address
n Reinterment I
Date ` Cemetery Address
: Permit Issued to i� 1 Registration Number
Name of Funeral Home 1 . T\(X 1 e ccx\ hD A—T1{ C,;1\ i)C
Address
1k Lc -`l t -\4Q- =--�- C :C.L‘-,5\J:_: - i Ky till_Opt
Name of Funeral Firm Making Disposition or to Whom
f Remains are Shipped, If Other than Above
• Address
l
LLl
Lta Permission is hereby granted to dispose of the human remains described 1I ove as indicated.
Date Issued�j ( � )�(}l Registrar of Vital Statistics _ , �- . ' -\
(signature)
District Numbe(Scoc-r-) Place 1 O L— o-1 n ^c
I certify that the remains of the decedent identified above were disposed of in ccord ice with this permit on:
Z
W. Date of Disposition $'/U It Place of Disposition �ti.i, ... C.mrdt'.,
a (address)
EC (section) f lot number) (grave number)
0. Name of Sexton or Person in Charge of remises ,If,, �a�n�
(plea le print) "�
14 Signature II Title `�E4041
(over)
•
DOH-1555 (02/2004)