Jasmin, Eleanor .INIEWICIRK STATE DEPARTMENT OF HEALTH BUrIa� _ Transit Permit
Vital Records Section
Name First Middle Last
Sex
Date of peath Age ( If Veteran of U.S. Arm-0 Forces,
O -Z/-v70/3 S6 War or D. 1- v
f
Place • .-.th Hospital, , titutio• or
C'4 , own Viliage0 vl e e,0s4 v,,,i Street Address Ll 71,�o ram,v,.��e F
Ma - • Death Natural Cause Accident Homicide Suicide Undetermined �Pending
Circumstances Investigation
Medical Certifier Name // T
4i . . �J? (:0/1) 'D
Address
l-� 7 oIA�74 /�i�� /1.7 l�� ati�eekis� C
Death Certificate Filed `s District Number Reg ter NurY><f
City, Town or Village S 7
Date C etery or Crematory 4
ii �� Burial a "�i.3 �;�.Q U., ('tin
Address cc
a-
•-: ID Cremation
Date Place Removed
fl❑Removal and/or Held
M and/or Address
a Hold
Date Point of
g Q Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
h
f� l K�rL1�. Permit Issued to jE<el -u��r� Home, Registration Number
Name of Funeral Home O!13o
Address /I LafaLte,tte of. , ( uRenS -r-j r Ne w L/vrk- l 2 A Y/
k Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:- Address
Permission is hereby granted to dispose of the human renains described ve as indicated.
Date Issued Q- a -x i 3 Registrar of Vita l Statistics , �.i.j i i _ ,
(signature)
District Number c s-i Place c. -.Jo>i
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZIL Date of Disposition ('Z1-1 I Place of Disposition Pill- VI etc)(lc-me-my
jj ti (address),
2 (s on) ( number) (grave number)
RName of j on or Person in Charge of Premises CO✓lf t i e. L L. OD 't eder
(Please pngtf)}
Signatu . k,- p T �E I
(over)
DOH-1555 (9/98)