Crooks, Beth MEW YORK STATE DEPARTMENT OF HEALTH T' 535
Vital Records Section Burial - Transit Permit
Name First Middle Last', �� Sep
to , ((m O 0
Date of Death Age If Veteran of U.S. Armed Forces,
`7/1 i f a viz C 1 War or Dates
• Place • Death i , Hospital, Institution or
City Town • Village !-I A d Le. Street Address ? 6-0 4 V;c v R, 4
p Manne • Death FANatural Caee Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
In Circumstances Investigation
Ca
tu Medical Certifier Name / "� Title
ha». 5-- P4e- ,,k r
Address / Q t
I oel f ar l( S j le-� /lr � A) 7 !ago'
Death Cficate Filed District Number _ Register Number
!> City, r Village ")G A Z / S ci( S
<> ❑Burial Date / a Cemetery or Cremat /
❑Entombment Address ��
®Cremation (2 c .s.. at Li
Date �) N Place Removed
❑Removal and/or Held
and/or Address
h_ Hold
Cl,
QV Date Point of
IZ Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date ' Cemetery Address
.inPermit Issued to - '"' e� Registration Number
Name of Funeral Home n . / A ns �o' 4 ell �'" .�-� c v 474471
Address
,S 4 cr.H.,.. 4v-e 6 t,\. N 7 I 22
Name of Funeral Firm Making Disposition or to WhorrI
• Remains are Shipped, If Other than Above
• Address
CC
to
Permission is hereby granted to dispose of the human rem ' described above as indicated.
Date Issued / "-/;Z ae,/7 Registrar of Vital Statistics r (
(signature)
District Number y 6-32. Place STY %j
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
tit Date of Disposition 1((1Iln Place of Disposition 121ntuk- C;,oh+rtor4~
(address)
lit
Ul
CC (section) �� (lot number)c— (grave number)
CI Name of Sexton or Person in Charge of remises 1 _ +� i
2 OIL print)
• Signature if Title OE 411114-
:.:::ii. (over)
DOH-1555 (02/2004)