Randall-Hayes, Valerie r N 41- -)7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
nii Nam First Middle Last Sex
ial P. koa.a�.\\- wa F
Date of Death - Awl If Veteran of U.S. Armed'Forces,
a 1-- c),p - a c 1 5 War or Dates N‘p
14 Place of Death Hospital, Institution or
City, Town or Village `a a Lwzunt_ Street Address L (Za, \.\
Manner of Death v. Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
in Circumstances Investigation
Ili Medical Certifier Name Title
> �-zter,,4P _ Act 0 ),� M is--- .
Address 76 7 M ,.,\ YI • ,� :.�r �'�
Death Certificate Filed District Number Register Number
City, Town or Village LO1.e,Ut ,r n-.AL Sip 5(Q 1
<; El Burial Date Cemetery or Cremato)
❑Entombment l / --5 `/ U i ;it w',C-h., GSM�-�v r
Address 1
Cremation ( -L ' —1- Kf y,,, / d r�\
Date C--) Place Removed
Z Removal and/or Held
❑and/or Address k;;;
Cl,
Hold
Date Point of
i El Transportation Shipment
G by Common Destination
Carrier
iiiii
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Da, 13imOyp Ittn1raj I e coTilg
Address
7 5�tr ft Ave_ L ii yrd Ai v /de.a a-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Z
tU
fl` Permission is hereby granted to dispose of the hmains de cribed b ye as indicate .
Dili Date Issued /- �eg0/Registrar of Vital Statisti � w
as huma
� �� -��
(signature)
gig District Number ` Place beg_ JUL- NV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lii Date of Disposition //Mit4 Place of Disposition ` ,L..„
(address
ill
CC (section) /�J (lotnumber (grave number)
CI Name of Sexton or Person in Charge of Premises G�Cea -+lb
' ( se print)
Signature (J' /�r Title reic Aft Pifi--
(over)
DOH-1555 (02/2004)