Perry, Sarah NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
'' Name First /� Middle Last Sex
>': ga►-'fi4 !" t ehVy
Date of eat / 7/` Ager, If Veteran of U.S. Armed Forces,
�� 7 (� Y War or Dates
Place of Death /�� //� Hospital, Institution or 1
City, Towu.ur� c- l— ` Str wt Address i... C GPY/ ' I v
Manner of Death li5 Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined ri Pending
Circumstances Investigation
iii Medical Certifier Name -"-?, /�� Title b
Address re....
l)i car c , kr v
:> Death Certificate Filed � / 1 l'�' //� District�mb�r Register Number
City, Tdwrrer-Vtt ge -eye f `/(
Date '] (// Cemet r r Crematory/ //�
❑Burial �// .( r`j I h C V t ' � L Y- o'Yt (J L1
Address
LCremation
Date Place Removed
Z❑Removal and/or Held
r- and/or Address
I~r Hold
(l)
0 Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration ljb y
<> Name of Funeral Home (6 t/tr� /\/1 t (44 (141r
ii MCI,' O /4 /
Address 7 , v, S� r
(eloe f J �- �.
<' Name of Funeral Firm Making Disposition or to Whom /
t" Remains are Shipped, If Other than Above
MAddress
iiiiiiii Permission is hereby granted to dispose of the human remains described above as indic d.
Date Issued 7/579.(� Registrar of Vital Statistics 4414- 7" �
(signatures /
ili District Number � e'y
-612� Place J�- w /4lS, /ly
I certif.,'that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
LTA Date of Disposition 7-14-% Place of Disposition P3 N 1,4'E ) C'E , ';A'1 i HI
2 (address)
ILI
tI)
CC ( e lot numb )� 1 (grave number)
GName of Sexton or Perscc in Charge of Premises , fJ V �Tft' O
F - (please pnn� t �--�Signature4411,.
Title cfe. . /a5Ri ,,ssj /
DOH-1555 (10/89) p. 1 of 2 VS-61