Braley, Sally I . ,, 4' 3sr?
NEW YORK STATE DEPARTMENT OF HEALTH Transit Perm Vital Records Section Burial
Name First S�1 1 1 Middle A In Last rcilia_ Sex /-,
1
Date of Death ` Age f If Veteranetl ' of U.S. Armed Forces, T
yit Sj 13) ) �- j War or Dates �—
PI.ce of Death n WS
f S Hopit , 1nstitution oril*Town or Village l C�tret Address � G1/ S
c, *.nner of Death Undetermined n Pending
Q NatuFai Cause �Accident n Homicide �Suicide
Circumstances Investigation
J.
ill Medical Certifier Name Title ,,
P 1 OM ‘()11\1A{19l,\A_ Luroyvor
Address
SZ Hj\jIlcA \4Rve , , glens Fa1ls , 12.60
Certificate Filed District Number Registermb ,J
:'City, own or Village �'1\2;15 \0.t\S
:_<❑Burial ! Date i 1� 'ZO t Cemetery or rematory 1' , „ •
❑Entombment Address
__ emation t,�0.kk� ) � � / N y 12 go
Date Place Removed
Fi n Removal and/or Held
and/or Address
crt
Hotd
0 ' Date Point of
lik 0 Transportation Shipment
by Common Destination
Carrier
0 Disinterment I Date 1 Cemetery Address ,
Reinterment
i Date i Cemetery Address
Permit Issued to ( Registration Number
Name of Funeral Home Nar— ;- es x\ ND-'i1{- ! C)t t . 0
Address
\' LeSc`- t_ -,-- C c,cc:_,-,s\L:._ 1 r K\k 1Z`cy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
Ill
mi
Permission is hereby granted to dispose of the human remains escri ec: boy s indicated.
GI /7 Registrar of Vital Statistics � `'` .�
� Date Issued 13/� 9
/ (signature)
District Number ,3-4(j/ Place �zoA,"X
al I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fit
'0 Place of Disposition
�ei ll,.� i��� a�
Date of Disposition ���� P
(address)
ILI
2EE (section) f (lot number)sir c (grave number)
el Name of Sexton or Person in Charge of Premises L^f `�.N4 j
(pleas print)
bu Signature -/ fir' Title (REM 1V
(over)
DOH-1555 (02/2004)