Loding, Linda NEW YORK STATE DEPARTMENT OF HEALTH p
Vital Records Section Burial - Transit Permit
,; Name Fast A� Middle _. Last _ ,.. ....... .. .. S,e�c
Date of Death Age If Veteran of,U.S.Armed Forces,
i a
�.;:� �� �/ 6/�"" �6 War or Dates
,..• Place of Death
•,� Hospital, Institution or ,-
Cam,Torn n or ,, _CC S .c- Street Address �g'-o .5. f1}-1L5 &5,,,, /-f
Mannar of Death 51; Cause ❑Accent 0 Homicide 0 Spade ❑Circumstances Elt lotion
Medical Certifier Name Title
Address7.
Death Certificate Flied District 6 4_,,,,.,,_,t. (AI . (2
Ni bar R stet umber,
City,Town or Villa e • 00 0 / -1 ILO
Cemptery or Crematory _
W.
❑Erstorn tt Address a'
ckt
It cremation / R , a& 8
0.
0 Removal
fHotelor Address
Date
0and/or Held
Transportation Shipment
Commonby Destination Place Removed
Point of
Ea•r. Carrier
x ❑Disinterment DateCemetery Address
Reintarment Date Cemetery Address
t">y, Permit issued to - Registration Number
f--
Name of Funeral Horn l '5( 441
iAddress
IA Name of Funeral Firm Making Disposition or to Whom
IRemains are Shipped, If Other then Above
Address
3:. Permission is hereby granted to dispose of the human remains d indicated.
�: ���t Date issued /0/0th0l1" Registrar of Vital Statistics
.41 0signature
District Number 0/ Place ' „,„ Ali � 1
5 i ei,I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /019 Hi Place of Disposition • N��� l' �,
I -
- (grave number)
NameofSextonorPersoninChargeofPremises ( �1 r /^ .J`77 e+,tiff
please pring
Signature l✓f c' Title SE^"
(over)
DOH-1555(02/2004)