Furushima, Chiyeko /NEW YORK STATE DEPARTMENT OF HEALTH - '; g 7i
Vital Records Section Burial - Transit Permit
Name Frst Middle Last Se
G'iiiyeka tui~ ush i0,a_ �Al__
Date of Death Age If Veteran of U.S. Armed Forces,
/7-0 7- <�0/8' ?� War or Dates NQ'
.i. Place of Death Hospital, Institution or
1 City, Town or Village Sc`j y-U p 1a,� Street Address / 74l�jY V 5 7
O Manner of Death im ,atural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ili Circumstances Investigation
at Medical Certifier Name Title
S ,ra-h rii c m P.s c'x' m -0
Address
lei Ft -Fi° Jc 0V42— S roe kA ,6--, a.oe> 12170
Death Certificate Filed District Number Register Number
City, Town or Village G�j /l) /5 i3 t a
<; ❑Burial Date / / cT/ ? Cetery or Crematory❑Entombment // Y//vc VietV (`-i-frrl A l O r<
Addees ,
Stremation oe-ou5 6 U N '
Date / Place Removed
Z Removal and/or Held
2 ❑and/or
F; Address
CO
0 Date Point of
❑Transportationfi) Shipment
Cl by Common Destination
Carrier
❑Disinterment Date Cemetery Address
!ii ❑Reinterment Date Cemetery Address
Permit •
ameIssued to d a)04 Ke.47-i /,.e,'g/ Registr Nu(ber
Name of Funeral Home ► � ,u_ 7
Address
Name of Funeral Firm king Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
CC
w
CU
Permission is h reby granted to dispose of the human re ins described above as indicated.
Date Issued/ Registrar of Vital Statistics 7{;L_i c� 56 Li'(�:L.�.c
7 (signature)
District Number /57,3 Place dc. ,,--9,_ /u2K
I- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ill Date of Disposition /f/il dig Place of Disposition �i,..I _ (A ,
W (address)
U
CC (section) /qof numb r) (grave number)
ci Name of Sexton or Person in Charge of Pr mises f 4►��, )iv-W1
(glee print)
;i S41 ignature Title
(over)
DOH-1555 (02/2004)