Loading...
Dean, Jennifer NEW YORK STATE DEPARTMENT OFiHEALtH Vital Records Section i Burial - Transit Permit Name First Middle Last Sex (Ten►ni lcr _),)n ) f'• Date of Death If Veteran of U.S.Armed Forces, p.` y/ l8/261-7/ 39 Dates i--t - of Death /i / ospiitai titution or own or Village C�_l e i 1 l�S Street Address �/..p ji r Fa_ `IS 65lo! -z net of Death�i Natural Cause Accident Homicide Suicide Undetermined 1-1 Pending Medical Certifier Name / Circumstances Investigation tl ri /C L 1 c-g- Title Address I OD A$YL fit.- S % CL.er.45-S Emus / ' th Certificate Filed District Number ` a( Register N�)umber (C y -own or Village (/, di tgf.4.S Date /R! 7 Cemetery or rematory_ A L,Burial i,w- id,-3 Address r� Cremation V g'1�b� ��J i, ut u b1r-,J&2 ��'`� Date Place Removed Removal and/or Held �-• and/or Address _ ii Hold 0 Date Point of NQ Transportation Shipment a by Common Destination Carrier [J Disinterment Date Cemetery Address Renterment Date Cemetery Address Permit Issued to ,� l Registration Number Name of Funeral Home/; rC b. 'Baker- runes/ }tome_ Of 13p • Address /1 Laraye#e a , e SIOU- ,jv %c) JO gol Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above `'vW Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued Li I i ri l 1-1 Registrar of Vital Statistics L.A.) (signatur) District Number 5 b©( Place 6 V 5 - \1 j _ N .( I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F taDate of Disposition tit 2c i i lace of Disposition g-1 V 4.4 i ,v,, '�a - a (address) iLl so lc (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises L 4:+f f,w t 1rt F (please print) .. Signature Zi ;4 Title G PAf lba. (over) DOH-1555 (9/98)