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Corliss, Nancy Lee
NEW YORKSTATEDEPARTMENTOFHEALTH Burial • Transit Permit Bureau of Vital Rewrde Name PoA MiOdk Inn Ys RFrlkn ye I(Velemol xSAmN fwa; TaYme WxarDMa Pikod xmA 1N InStitlNona. Clay.Tomorl6liage GpIEGwsd Tom Artel Aldreaa FnIHUJon Nura�q CmXa,lx IN Manaao WmA ® Nawni ❑Aaiaml ❑Hwwewe ❑swca, ElWememi,ea E IRnm<d,n, rn�msamaa I IN MMlmlEenniar Xam me, ciMMM PA Adwesa 91p81aedwey, FMEWdtl Tvm,Xw YM 11BID GSACenF aM M inrit Wainer RehearNumber C .iownu Vi FEMVJ 5)55 5 Burial Date FemXerV.Uamxerywfai4rywme ❑fMomAnanl mITY1w 0 Pm Vbxcrem Address ©tremMin gyomure Town.Won Yore ❑oemmX o F1Anon Dale Flaxhnvrtd "N,, adh,WW N Holtl AdMeas g �nnmpwWim Dale - Prieto S Monument Shipment Cale, Demnalon �DisinXmrem D.X @meery.wdreaa Elxmennem We QmeaeryAddreaa Namm"ol FuNro p[y'mati[n NumM Naure,al Home MBKIImn FunaelXwre-FM EPwd DIOIB Address 82 Name of way, FMr,Mn Now YCA 11828 orr Remain To went Firm MOtherthan Above orw WMm f Address It SAi IIDtMrallanAmae It Aderz 6 W LL [irmlWen is Nxaby proofed mtliapweWNe human ramalna deeGlbed abnwxlnUlrJ4tl. Data Haued aynamo Pegima,avielsmisw almea arabarryl'ec emnvu¢ysygnM/ okwlwel Unlit Number area PI+e FMEdnera, NexYM I,enihu,Atle remdru of Me daehm icenllHed abye wem diapwed or in Awrdme wm Air W mBun: WWko p,pailbn reedm pimdDa, - a � owmrr w i ram�wew None,wean gNa et w e, ,re mKAa remi pTaarervMu '� spnmum rnla r DJ&a5551o1hel prafi Public HeaRh Law sec. 4145cPbj ` `• 7111n� Receipt Human remains of i`,�1(`' _i 1 « deliveeed oniamewMcemOfficial °f°ry aepm rnuue moe[wnnl LnmFlmeml olreaon Reg oe rm