Swinton, Christine NEW YORK STATE DEPARTMENT OF HEALTH . A 1 31
Vital Records Section Burial - Transit Permit
Name rst Middle Las Sex
l`1 V 151-1 70r✓ J� . J�Lc3 i AJ CoF2�+I A/e�
Date of Death Age / •
If Veteran of U.S. Armed Forces,
dd. - Qq- �1 l� y War or Dates Ai0
j- Place of Death Hospital, Institution orr
W City, Town or Village SC/4 rCO A) Street Address �� 0-5 /er 9
a Manner of Death Natural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
c)I DA UhmAe in D
Address /
3 'I4'1 (7>ni0 sr tO A rj'easbcry /v. / ae
Death Certificate Filed District Number _ Register Number
City, Town or Village ScJ rd04 L,j ‘3
❑Burial Date CP
etery or Crematory/
['Entombmentntombment O - 0 7_ o f 5 ,Ve ai etl) C r Ardis-
./
Address
:< Cremation qt,„e..),, ,,,, �- ,
Date Place Rer>'Soved
Z Removal and/or Held
❑and/or Address
Hold
-CO-,-
0 Date Point of
efi❑Transportation Shipment
6 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
�(Name of Funeral Home EWlq y-d. I, _ �� oitJQ Yr4 I ad yyl.t- r $" I
Address
c ,/,_ Fey___- A)Y- / - 70
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;Z Address
tr
to
` Permission is hereby granted to dispose of the human remains described above as indicated.
inii Date Issued a-6)9_90/S Registrar of Vital Statistics T `�l f7LGe-(.j2— a ilQ-tuL*
/` (signature)
igii District Number 1 5 Place 3 ,f� c-,-,ik) pox,
.„,:„, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
lit Date of Disposition Z 1 i1 fj t 4 Place of Disposition e�V 41Ad--
1 (address)
C
CC (section) A (lot number) (grave number)
0
a Name of Sexton or Person in Charge of , emises ,(nl i� Sf,. ,tt
(pl ase print)
w.
Signature F°' �" Title (00)1112,
(over)
DOH-1555 (02/2004)