Liberty, Joan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
F c ±c-C �
�L IDE
Date of Death �� , Age If Veteran of U.S. Armed Forces, ' i CFI i i War or Dates l ,
1- Place of Death Hospital, Institution or Ap I Z3
5 City(wn r Village .QQ,Y) v"-" I Street Address 6'0 ee(e)ayeeIt\ (--CAYNe
0 Manner of Death Natural Cause Mcident 0 Homicide ❑Suicide Undermined Pending
Ut Circumstances Investigation
0 Medical Certifier Name `Title
Address
Care AC'
Dea ertiticate File Di t yber Regisumber
Cit , Tow r Village `, ) J1
:�Burial Date p� Cemetery or Crematory
12..‘ i ?01 I\\Qt\onsLks -__- .►\ltri
❑Entombmenti
I Address
OCremation C\-:,)k(>0_nS\O(' 1 to y
Date I Place Removed
t-❑Removal and/or Held
and/or Address
I Hold
d Date Point of
Q Transportation Shipmentla
G by Common Destination
Carrier
Disinterment
Date Cemetery Address
0 Reinterment Date Cemetery Address
1
Permit Issued to -. — Registration Number
Name of Funeral Home - G' ! t �C.' _ .
Address
11 La-IC-VC-Li C .At Cc t ) Qtt.t>c i i t)(.4, f / , N'C t,.,,F y ti- k 1, eV-_)` I
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above —
;; Address
CC
11.1
11 Permission is hereby granted to dispose of the human remains described�j a ove as indicated.
Date Issued i 1 g )c)pi( Registrar of Vital Statistics Wi ri� t - lL .__
(signature)
District Number Place 16 ` ____`D. QL
I certify that the remains of he decedent identified above were disposed of in acc, da e with this permit on:
ratr n
W Date of Disposition } r, \ Place of Disposition i 4 _ kted 3 b,,k l v_
,' . (address)
(se o ) (I n mb ram) — (grave number)
A 644
Name of Sexton or Person in Charge of Premises ___ _
Zr (please print)
W Signature . title --fir a(1 Cif -- --
(over)
DOH-1555 (02/2004)