Smith, Doris NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle - Last Sex
;)or-i% �.. S cr`, T h C�
Date of Death Age c If Veteran of U.S. Armed Forces,
c� 'JJ 1 1 1 1 War or Dates
144 Place of Death r --i_ GIL r.
,(Tow QLA-J-s-fl%bL r\I Street Address
Manner of Deat�'�(Natural Cause Accident Homicide 0 Suicide D Undetermined Pending
Uil' Circumstances Investigation
w Medical Certifier Name Title
Address
) j"- Cc_n or- tr- , ) 0.LA Q_Q Xl S but r y j m 1 a % `-1
Death Certificate Filed Dtrict Number R inter Number
Burial Date Cemetery
o � i � Fw‘e \l iew
DEntombment Address
.UCrema ion
Date Place Removed
Removal and/or Held
and/or Address
I= Hold
U)
0 Date Point of
lik D Transportation Shipment
E by Common Destination
Carrier
Q Disinterment Date Cemetery Address
D Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home F 0 QX d .. . PD a_k e r 1-L-L-r12 ra l sa._ 01 )
Address 1 \ L Si', ) QL,Lk. bur i, N`-i t C>k-i
Name of Funeral Firm Making Disposition or to Whom
}►• Remains are Shipped, If Other than Above
Address
CZ
tit
Permission is hereby granted to dispose of the human r mains described above as indicated.
_
Date Issued �j�a . 1 Registrar of Vital Statistics
its:_—_,_
(signature)
District Numbers (i c 1 Place \ ( ) tL�'Z 4 (:).W2...52.-- 4:3\-i -..--/
F I certify that the remains of the decedent identified above were disposed of in accordance this permit on:
Z J
ILI Date of Disposition 1 2/3 0/1 1 Place of Disposition Pine View Cemetery
(address)
U) Horicon 3 C 1
CC (section) (lot number) (grave number)
Name of Sexton or Pers 6 harge of Premises Michael Genier
.fir (please print)
i SCi- Signatures .� '.- Title Superintendent
(over)
DOH-1555 (02/2004)