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George, Evelyn '- NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex �� t1/1 _ ©r F Date of Dea - ' Age If Veteran of U.S. Arme For 61-1�2 12013 _72 - or Dates "/ ld' - rCicyrof Death Hospital nstitution or own or Village GleAs r-cd k _ Street Address Gi r1) F-a.11S }Ao pr1-tiW 0 Manner of Death f-pAatural Cause 0 Accident 0 Homicide 0 Suicide EjUndetermined ri Pending III Circumstances Investigation W Medical Certifier Nam Title A . �, t�� Otrli fl(� l � d_ _ til___, T_____ Address r Death Certificate Filed ,Th District Number Register N tuber City. Town or Village ;-I&y}5 I'a q5 Si if/ i geurial Date I 0 1-I + 2S-113 Cemetery or Crematory r'0e _ : + ?:�e _ _ ❑Entombment Address - - -0 Cremation Date Place Removes Zr-i❑Removal and/or Held and/or Address Hold O Date Point of NQ Transportation Shipment O by Common Destination Carrier Disinterment ! Date Cemetery Address Reinterment Ei Date Cemetery Address Permit Issued to --`N - ' Registration Number Name of Funeral Home t lG\I(1C..i d 1). 0C.Kt-I lit CL ( H0(-)1C: 1 Address l i Lct-f(i /C-11 C <�-1r (:( A , Gt tCC ( i'„,ti i.t t / , kicv, l r }< i ',j C it i Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped, If Other than Above T__ _ 2 Address CC 11t- -_ - 0. Permission is he eby.granted to dispose of the huma remain •escribed above as i icat d. Date Issued 3 OLE Registrar of Vital Statistics cJ22 :` G �j (signature) District Number .. Place `( i Al Ste/ ��s � �f '/ I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on: Z Itt Date of Disposition 4-25-1 3 Place of Disposition Pine View Cemetery -- ------- - (address) W Erie 65 C 2 to CC (section) (tot number) (grave number) Q Name of on or Person in Charge of Pr mises C• nie �Qedert (please p,ant) Signatur - - - Tit : , - r Q•� _ - (over) DOH-1555 (02/2004)