Dygert, Jessica NEW YORK STATE DEPARTMENT OF HEALTH 231
Vital Records Section Burial - Transit Permit
Name First Middle ast Sex
-JCS S M. Liy d-c
Date of Death Age If Veteran of U.S. Arm orces,
63 I/5 Po t 9 36p War or Dates
Place o eath Hospital, Institution or
City, ow or Village Cti1eS- ,e- Street Address
Manner of Death ❑ Natural Cause ZAccident ❑Homicide 0 Suicide ❑ Undetermined ri❑Pending
f Circumstances Investigation
Medical Certifier Name Title
Address
'htcc S�4 el,c} h 9
13 -✓ St IC rif-0 L619. . FM. 12--W e.
Death - "ficate Filed District Number' , Register Number
City, MIrhirir Village (' cle5-}-t 5( 5 Q 3
Da e t� for/Crematory r -
❑Burial r 1c1 <Do I ) I Ne Vie C're c +orior►'1
•� -rss� ^(
2-Cremation Aar
a O e1 /U OeC�sbor AJ \I 'D u V q
FDate Place Removed X
0❑Removal and/or Held
r- and/or Address
Hold
Q Date Point of
yQ Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i Permit Issued to Gqi-joy-N
tfrs
�� �� / Regis Vn N2 b j
Name of Funeral Home 0 Ulle t l
Address
1111 r i-►-P S-I- 0Aes 6 0(2)e, W( 1. 17
„ : Name of Funeral Firm Making Disposition or to Whom
w' Remains are Shipped, If Other than Above
Address
W
C
Permission is hereb granted to dispose of the human remains escribed above as indicated.
Wi Date Issued 05 lig 00(6 Registrar of Vital Statistics
(sign ture
ipi District Number (c Place 0 l�r� CD ��n�c� �
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- /
W Date of Disposition 3/70 lit Place of Disposition _ 4..i r �A..
2 (address)
t!J
N
CC (section) J(lot number) (grave number)
GName of Sexton or Person in Charge of Premises ,
z
(please print)
Po! Signature /L Title /11400
(over)
DOH-1555 (9/98)