Sabin, Elizabeth 71
NEW YORK STATE DEPARTMENT OF HEALTH b ~` :Z (�,
Vital Records Section Burial - Transit Permit
Name First Middle Last . Sex
. *ALe/3 r# /77, sae/AI Fb7mnth
Date of Death Age If Veteran of U.S. Armed Forces,
RPRfh. O 7 dO/S 9.2,1 War or Dates A/Q
10.. Place . Death Hospital, Institution or
X City, ow 1.r VillagefOR T',4,�/,(/ Street Address g cf 6 o omAN 04 t2,
Manner of Death g Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
tit
Circumstances Investigation
W Medical Certifier Name Title
(Pi 9ta. IR./ /G /oAi m 0
Address
SRon<G ATE erg', GL,�7VS'/ci4LL.$ /c 7 /��O/
Death --. .cate Filed District Number Register N mber
City, own : Village feet RAM/ S7Sire
El Burial Date Cemetery or Crematory
❑Entombment a f aciVe p� /-� S Q//,/G�l'/z7.(J a R6 27/9 TO 44/t/1Y?
Addr ss
` gCremation cC/E.EA/Qati0id ivy / FO5t
Date Place Removed
42❑Removal and/or Held
and/or Address F;,;
Cl)
Hold
0 Date Point of
t aL❑Transportation Shipment
C by Common Destination
Nil Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iN Permit Issued to Registration Number
Name of Funeral Home/Y//3 SON N ??,cL ma" /'//'
Address
cc'o•ci3ox , 7nFoer,q,i,q/iy, /--o' 7
Nli Name of Funeral Firm Making Disposition or to-Whom
Remains are Shipped, If Other than Above
Address
a
la
P.` Permission is hereby granted to dispose of the human retpains described ab veaskndicated.
Date Issued . 4f_ egistrar of Vital Statistics 7'1/711�,s. /',c,
(signal e)
District Number Place i
5�-�s' C'a agT .vy, �c/y/- /. 'z
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition Ig +�6� Place of Disposition Z,u�,.-,, Zr�`tor,„.r
E (address)
ILIA
CO
CC (section) I tt number) (grave number)
Ci Name of Sexton or Person in Charge of Premises AI+ 3
z (ple se print)
ja
Signatures Title ` E"04.
(over)
DOH-1555 (02/2004)