Mead, Ethel NEW YORll STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
�<:' Name First E+JI Middle 6 Last
��:: mead Sex F
Date of Death 30 l 3 Age Q f If Veteran of U.S.Armed Forces,
War or Dates '„
�{�
w
33:_. Place . I,-. kt/J
pD^^��City, own ' V c S >;J P y treat Acic a 1c OWL i it l I - :.
Man Natural Cause 0 Accident Q Homicide 0 Suicide 0 Undetermined Pending
Circumstances Investigation
''- Medical Certifier Name Title
lit Address
`gt Dea • - •11 ate Filed l, District Number Register Number
t C" Town • Yalae !(f z s g v7 s7& 1. 0 6
Date c.errrtery
Burial 3 1 �+ne_V i e v&3
•
: . ❑Cremation Address a uo Ker- -Rd . , C u cenS bu2x r 7 1 0(sol--4
Date Place Removed
o Removal and/or Held
'•"' O1 Address
• Hold
Date -Point of
ya 0 Transportation Shipment
a by Common Destination
Carrier
Li Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
f- Permit Issued to ,/ Registration Number
`` Name of Funeral Home I ' na d eau-.�P U/tca,� -Home_ o/1 o
4 i 1 /-0462-Lftli, 31-,) Ct,t1212/16bUit-y/Y Address i&t-,/ O W 1 I
•N' 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 remains described above as indicated.
<.>:, Date Issued 6 -3 _aol 3 Registrar of Vital Statistics
iw?S
' (signature)
:> District Number �'7 6 Place /( ('2.lh 4 7C t 15
‘3„,_,-1
fI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
SDate of Disposition 6/3/13 Place of Disposition Pine View Cemetery
(address)
Sin
Sec. 27 Wah Ta Wah 141 4
LC (section) (lot number) (grave number)
Name of on or Pers ' - Charge of Premises Connie L. Goad e r t
(please print)
Signatu' ' Title Superintendent
i (over)
DOH-1555 (9/98)