Butler, Ann NEW YORK STATE DEPARTMENT OF HEALTH 41 (9 ( I
Vital Records Section Burial - Transit Permit
Name First ,ist Middle Is Se)
;NI..• -I 1 e V
iv
Date of Death Age/7 tc, If Veteran of U.S.Armed Forces,
/ --)43--/C7 War or Dates
A Place .' 0-ath Hospital. Institution or
F.=. ,. City, owns Vigage or37 fre21./ Street Addr 2,C 7 Ck ,71
a Manner • Death"IN Natural Cause 0 Accident El Homicide []Suicide ID Undetermined n Pending
Circumstances "'"'Investigation
ni1441 Medical Certifier Name Title
'IP to;(1:147ri t 0 t-I lt K Co vvivele"
Address
,ifig, D 4 y-vo cv 4 L.)ide Rd,-64 e 6 rerliAc my-r i'ill7
fe Death Filed District Number - I Register Number
City,Town r Village 73p(re7 ek/ o7,5e) il
_...
--..:.:. ,_, Datq,_ CeAretery orprematory
Li Burial Pe-c,,3P-10 t".4)Y1 e v,eri,A)
Addr -
:•:-:4,1 Cremation cAteeNy beisl, nty.
.....
.....
:.: Date Place Removed
Z 0 Removal and/or Held
-14 and/or Address
a Hold
0 Date Point of
0 Transportation Shipment
Ej by Common Destination
Carrier
[]Disinterment Date Cemetery Address
...
...U,--,Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 14.12,h R
O- telt__ Fa1.4-c__Atire:- oil vy
7 _Jo Address
// (.-grOyC7-76- ' 0 u4s1 ---A.LC IS Ogy Ay /24F-6 'I,.....
Li* Name of Funeral Firm Making Disposition or to Whom s _
:..gi Remains are Shipped. If Other than Above ..
ia Address
41
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• Permission is hereby granted to dispose of the human ns described above as indicated.
P Date Issued la ".17-Joio Registrar of Vital Statistics i A'AAA__./.1‘(signature)
District Number 5 ) 5-0 Place )/i-b -\ I Ct/Y1 Cii7r,j , iq
...
-....'-': I certify that the remains of the decedent identified above were deposed of in accordance with this permit on:
.F,
Date of Disposition Orc 3i.) 794)Place of Disposition --Pm..e.,0 to4.4 Cr".c-tar
2 (address)
UI
Cl)
LC (section) A (lot number) (grave number)
Name of Sexton or P rson in Charge emises - ( LT.i•ikek -'.- 1 '1A-A1-
2 9 .j/-1.,, (please print)4 Signature Title ci/izni hi OCL
..
- (over)
DOH-1555 (9/98)