Nelson, Velma NgW YCaK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
• ` Name First Middle Last Sex F
1...
\mC nCes N6SOn .
Date of Death Age ( If Veteran of U.S. Armed Forces,
i 6 War or Dates k )11-
•r•
ry Place th f•iospitai, institution or
C Town ViU�eCYIS�OIL rY Street Address Wl �crlO�r�- �cP.gl�-Y1 ,1i�
Manner of Death t✓""!Natural Cause Accident Homicide Suicide �Undetermined Pending
�! Circumstances Investigation
a Medical Certifier Name I` ^ f) ��c,D� Title R t)
Address 1SM urZ i zgcy
WQSri\Cvon}- \-Ee.cl l Rc%'14-y Gunn RN Lo.n nAio ry
zscs
Death Certificate Filed i-c�Nialer r�ttc Number
• City, Village �bHf�— _ L, J
C� Town or Vi e
Date Cemetery or Crematory
:..,. �Buriai l 2• 101 I ?_C�1'J Pine_ v i rv,.) CP.rl1P ef
Address
Cremation Q\Kire`nS C' l K)I
gDate Place Removed
g Removal and/or Held
t� and/or Address
k- Hold
Date I Point of
I Q Transportation f Shipment
a by Common Destination—
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Na Issued to ^^ �key �c�t On
I0Number _
NamemeHa Registration of Funeral Home hQ.rd U, rte�rz/ Home
Address I L Fa y ate (5F. , &uterisbury,)1 e w York l a e041
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 ins described as indicated.
_Date Issued} ISi 30\-Registrar of Vital Statistics � Ot ^ A
',,signature)
4 er- �9 District Numb l Place t 0 ut-r 6' (_tu/D , S
I certify that the remains of the decedent identified above were disposed of in accor with • permit on:
f
5 Date of Disposition 1 2/7/1 3 Place of Disposition Pine View Cemetery
LM (address)
IA Seneca 20 E 2
>C (section) (lot number) (grave number)
AName of Se nor Person in Charge of Premises Connie r,. GoectPri-
2 Cl r- (please print)
Signature , UAUL -ed—e,v1 Title Superintendent
(over)
DOH-1555 (9/98)