Levandowski, Susan a
NEW YORK STATE DEPARTMENT OF HEALTH Burial m Transit Permit
Vital Records Section
Name First Middle Last ( Sex
-S ysta,J �yA;�a" Li—ueA) z%0,,,s(<,f I F rn 1
, Date of Death ! / Age 1 If Veteran of U.S.Armed Forces,
_; 2- Z,cf/(7 7 e 1 War or Dates /dig-
Place • Death Hospital, Institution or
III City,IIow. •r Village Q o d�-►.r$ Street Addr_e i o /y,g the—A.a 1-61..f
0 Manner of Death aNatural Causeccident El Homicide D Suicide El Undetermined { I Pending
Lti Circumstances Investigation
la Medical Certifier Name Title
0 Ai c z.66( c--7) ✓cAJc /l, !)
Address
J/Mh',) 3� S'—, (: 0,.n E-ezc,c A/ /aPO/
<> Death Certificate Filed District b r ' 'Register Number
>. City(`fawn�r Village Q o A..;i u7 � 0 _
�Rurial 1 Date I (,Cemete Crematory
.;. []Entombment` Z Z� (7 ,�cr + tte�
Address (f
:! ❑Cremation Cz u aY�� itio , (- Ocol,.r:tQ v `1)y
I Date Place Rem d /
2 t Removal and/or Held
9 and/or I Address
Hold I
0 ' Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
C Disinterment Date Cemetery Address
Reinterment 1 Date ' Cemetery Address
Permit Issued to i-� Registration Number
.Name of Funeral Home 1 .�'\C_ L ilLcz?� ill.(.:-'.-
\ Hp l . C:,t i 0
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
2 Address
CC
Ltd
! Permission is hereb� -) granted to dispose of the human remains, described a v as indicated.
o� 9
Date Issu ( Registrar of Vital Statistics C^ ( 1�
_ (signature)
District Number S ) Place c...--T-- O CD
I certify that the remains of the decedent identified above were disposed of in acco dance ith this permit on:
14,
ILI Date of Disposition /� t /7 Place of Disposition 2/ (a/t t r 'u . e u z='���%c k/
l (address)
la
k�PneS/(yur 1/5 a%
(secpn) (lot number) (grave number)
0 Name of Se n or Person in Charge of Premises �-V aN�' L �a G u L i
Z (please print)
Signature /1 4.&e 141 Title, CAR uL-41•e--x_kx-e
i
(over)
-
DOH-1555 (02/2004)