Camp, Ruth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
I
Name first, ` _ i M Lastex
Date gf Death' Age If Veteran of U.S. Armed orces,
1 I —1 t s 1 -, t 1 War or Dates
} Place Death Hospital, Institution or
111 Cit , Town o Village Q ,2h Street Address
0 Mann o Death[Natural Cause ❑A�cc •ent ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Lit Circumstances Investigation
0
Medical Certified_.--. Name itle
o Cahn L.
1 ly Lc.x-ems . , -f5� ry-t 1 OL#
Death Certificate File D trict Number Register Number
Cit(Tow�illage e. ��� 4 Qp
urial Datek. i ¢`rnetery or Crematory,
l 1 (`52.�11�-0 h._4
Entombment Address
Vi OCremation 4—Z1
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
~ Hold
'I)
0 Date Point of
l"0 Transportation Shipment
C3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home day 6,,Q,4 80,_key-- ri- - ;e 0 113O
Address
I 1--c --�a 6) P *17 �tr1,om1 r151�If,� N y I2 O 4-
Name of Funeral Firm Ma ing Disposition or to
Remains are Shipped, If Other than Above
2 Address
it
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` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1119 ) _ Registrar of Vital Statistics c:,„ C, �,1 ,(1,N_
(signature)
District Number„ Place�y—��
I certify that the remains of the decedent identified above were disposed of in accor nce ith this permit on:
k
lif Date of Disposition 11/13/12 Place of Disposition Pine View Cemetery
a (address)
inUl Erie 60 A 1
CC (section) (lot number) (grave number)
Name of Sexton or Perso in Charge of Premises Michael Denier
r _ - (please print)
Signature t Title Superintendent
(over)
DOH-1555 (02/2004)