Sawn, Sandra NEW YORK STATE DEPARTMENT OFHEALTH
Vital Records Section ��U8�^��8 ~ ����)����^� �������^�
Burial-- Transit Permit
Name First
CMiddle Last Sex
Sa
..... Date of Death Age If Veteran of U.S. Armed Forces,
wal
�A/ 7 6y War or Dates
Place of Death Hospital, Institution or
0 lvec-,2 s b Yee"= Alm,
Manner of DeathF]Natural Cause Accident [:]Homicide E]Suicide E n
-W Circumstances Investigation
Medical Ce Ftifier Name Title m
et v
va WV
Address
Death Certificate Filed Distfict Number Register N mber
4 d d r e-7 W
El Cremation
—bate P ace Removed
0 and/or Address and/or Held
Hold
0 Date Point of
(n F]Transportation Shipment
by Common Destination
Carrier
F-]Disinterment Date Cemetery Address
F-]Reinterment Date Cemetery Address
Permit Issued to
_5Lo, j(j,(/a,A ra ion um er
4f/1 P
Name of Funeral Home
Address
Name of Funeral Firm Makir4 Disposition or to Whom
Remains are Shipped, If Other than Above
Address
`- -
Permission is hereby granted to dispose of the hum re ins rspribe, a e a's indIcated.
D Registrar of Vital Statistic
ate Issueaq
hum
ital
O�h� Num�� ) na�
mx ---~ '
| oe��ythat the remains of the decedent identified ab v ' ere disposed of in jc)or ance with this permit on:
W. Date of Din position 9/8/9 7 Place of Disposition
Z (address)
Uj
Family Plot
(section) (lot number) (grave number)
Name of Sex Person in Charge of Premises Rodney G Mosher
(please print)
� Signature �� �- �� Title Superinteodeot
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DOH'1555 (10/89) p. 1 of V8'61