Poland, Edith NEW YORK STATE DEPARTMENT OF HEALTI- 3r b
Vital Records Section Burial - Transit Permit
Name First j~S im Middle rc .1 Last no j„ _Ar Sex F
. Date of Death GC 3OjZO)o Age I If Veteran of U.S. Armed Forces,
�1�3 3'1 .War or Dates 19I0.-MS
i- Place of Death ( etAdd
orTollage ci (,mress e lkitA Fal,.d.
cl Manner of Death[Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined pi Pending 1.14 Circumstances Investigation
tu Medical Certifier Name /l e Title
J e r/y l Coroner-
Address I3L)o State Roa.Lte q Lou C eca?, kV 12�yS"
Death Certificate Filed n r_ y r� � District Number Register Number
City.)Town or Village ( lSLI� 0` 3
0 Burial Date 5/3 i;g Cemetery dtCremator r p% ,,
[Entombment Address / nn
;Cremation 01_t_a_t QX D '' ,) 0,... Uiu.4, iuN J 2 wci
Date Place Removed
Z❑Removal and/or Held
and/or
I Address
— Hold
IA
0 Date Point of
ti Q Transportation Shipment
ci by Common Destination
.Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to �/ " Registration Number
Name of Funeral Home fl ttoi FG i raX hire, Inc. 007ZI
Address
/z CI'* Sf' i iaa-seujlle, II I I291414
Name of Funeral Firm Making Disposition or to Whom
fq, Remains are Shipped, If Other than Above
Address
ILI
LL Permission is hereby granted to dispose of the human remai s descri ed abbov dicated.
Date Issued Registrar of Vital Statistics G ' / a2i
� (si.nature)
.........z4LA3
District Number 560 i Place ce....
I certify that the remains of the decedent identified above were disposed of in accord nce with this permit on:
III Date of Disposition S 14 liq Place of Disposition ?N V,. ( -
W (address)
tfl
CC (section) Araot number
) (grave number)Name of Sexton or Person in Charg of Premises �a....A
+2. 6 (p! ase print)
ill Signature Title lhfiMttjn`
9
(over)
DOH-1555 (02/2004)