Turner, Wanda NEW YORK STATE DEPARTMENT OF HEALTH
Vaal Records Section • Burial - Transit Permit
Name First Middle — t SAC
Date of beat Age 1 if Veteran of U,S.Armed Forces,
fi�rr'' �+
(�"l-l`I- `-z �� i War or Dates
Place • e-athHospital, institution or
C" Town •r Village I V`(" I Street Address
Mann-. •- b'at hlatural Cause ❑Accident Q Homicide E Suicide [J Un termined D P
Circumstances. ,,t lion
18,1 Medical Certifier Name. Title.
Address de),_ (C3s` Gex\S os\ ,u 766\
Death ificate Filed 1 District Number Register tiler
City, or Village 6�tSJ. j S Io.Z 9
QBuria Date 1 Cemetery or ..a ; _.►
[ Entombment Address n1Sx
remetian Q UC.- •sj 1\.1
Date i Place Removed
o Removal and/or Held
i -, andior Address
Holes
Date F Point of •
O Transportation 1 Shipment
by Common Destination
Carrier
[J Disinterment , Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to ‘i abort Ntsrtber
Naive of Funeral Home 'C-\, co s�— T �a���
Address
1 c .Y. 4. \''' Cems \S' V \276 .:
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ua
Ili` Permission Is hereby granted to dispose of the human remains described above as indicated.
Date Issued // )/ IV. Registrar of Vital Statistics // C-4/--L-
District Number vs( a Place 70 az? a fi yo ok e e l c.. •
ir;
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
#" Date of Disposition 4/1C 11 i Place of Disposition f t U....1 Ire ,,
oax.,g
(address).
la
{sect Ofl) //7// (1 »umber) (Breve rraurabexJ
Name of Sexton or Person in Charge of Premises `A� �1^++h
�� t se Pont)
Signature d Title _l 'r itil1t.
(over)
DOH-1555 (0212004)