Ralph, Dawn N. # 30Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name t addle Lasrix, Sex
,kt
Date of Death Age If Veteran of S. Arme�9 orces,
�o?y ! 2 �� War or Dates
Place Death itai, hnstittlfion or
Ei City To n or Village ,L,Q/fe Z�z/,-.c Street Address 7/ y,5-f f/ 1/e�- )/?
Man of Death pNatural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
in Circumstances Investigation
ig Medical Certifier Name r. Title
44
Addres�ss boil' n
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Death Certificate Filed �� r° District bs-? Register, amber
City, Town or Village Filed/
/ (v "�
CI Burial Date / Cemetery or Crematory /�
`f/G / a�i 2� ,4 c V: v. L._1�e..µ ti6/ty�
['Entombment Address o
' Cremation r�,,,h , , /�� /°r
Date i Place Removed
❑Removal and/or Held
., and/or
Address
CA
Hold
Date Point of
ei❑Transportation Shipment
E: by Common Destination
Carrier
❑Disinterment Date Cemetery Address
[]Reinterment Date Cemetery Address
Permit Issued to Registration Number
ar2
>' Name of Funeral Home �J(� 7a,,e,--ai 9�/'fc' n_e_ Go`tom
Address 7 JJ�e,/z a0 Av& ( Uri J7 AI/ /? ? i
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
i J
`: Permission is hereby granted to dispose of the human r a' s describ above as' 'ated.
<` Date Issued (Registrar of Vital Statistics ,, iLL�
zii
�� (si ature
District Number 3&Place ix
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition tail,lit Place of Disposition pk.V� (/r
r-1
2 (address)
tt!
tO
CC (section) (lot number)(_ (grave number)
Name of Sexton or Person in Charge of Premises --) -"
41
// �( lease print)
la Signature (,.J` K- Title 1tzL°Mfm'_
(over)
DOH-1555 (02/2004)