Germaine, Sharon NE.W'-6 K STATE DEPARTMENT OF HEALTH B4' ansit Permit
Vital Records Section
Name First Middle Las, Sex
S r a _ - SuU to--rr� 4' r . fern/ate-
,
Date of Death Age 0If Veteran Armed Ford.
1 /L);`/ ' `73 War or Dates .i �
}- Place of Death Hos ita, Institution or
Z , Town or Village Qui.-is F0-,1 Street Address Qi.e.0 F�-vLs
a Manner of Death&Natural Cause E Accident 0 Homicide 0 Suicide El Undetermined El Pending
ILI Circumstances Investigation
W Medical Certifier Name Title
Address
- — Ce..e.u F$-u� N_- /2,PO/
Death Certificate Filed I District Number �r�j Register Number
, Town or Village a L�,.ys Fig-as5ov) 1 Loci
aurial Date I Cemete or Crematory
DE I ntombment 9 j ojz �i� J,. Viet")) �'Lc �-6�d _
Address _
❑Cremation Que-rz 6 u „Js6 i'YL-y 47
Date Place Remo(ied
z Removal and/or Held
❑and/or -1
° Address
to Hold L_
? Date Point of
%Q Transportation ' Shipment
G by Common Destination
Carrier
} - — -_-
- -------- -- --- --
Disinterment Date Cemetery Address
} Date 1 Cemetery Address
0 Reinterment
Permit Issued to _ ; Registration Number
Name of Funeral Home Hu.y flCud U. ��c.L ke( f-L_Lne;6-I lc)re-*- ®U34_
Address (,
Name of Funeral Firm Making Disposition or to Whom
N- Remains are Shipped, If Other than Above _
2 Address
W -
fl.. Permission is hereby granted to-dispose-of-the hurnan`rc ill ains described above-as indicated.
Date Issued Cy / 3/t y Registrar of Vital Statistics fit., ,_ ��.��t^s 1
(signature)^
District Number 5 60 ) Place G 5 1 % iv '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 9/6/2014 Place of Disposition Pine View Cemetery
2 (address)
W Oneida 97 2
IA
CC (section) (lot number) (grave number)
0 Name of Se on or Person i ,Charge of Premises ____.________�O ie L. Goedert
CC lnlaa .,,......a
IItI l7Z,u Superintendent
Signatur _ __ —_ Title _.
(over)
DOH-1555 (02/2004)