Chenier-Seymour, Michelle NEW YORK STATE DEPARTMENT OF HEArTH fl q g
Vital Records Section Burial - Transit Per it
Name First n Middl , Last Sex
1��t c he i IC, Mar 1 e. he --I e. — Je r/1 o v r f eAlCk(e
Date of Death Age If Veteran of U.S. Armtod Forces,
j- 12- 7-0 ! $ 58 War or Dates
i Place of Death 1 ��---- Hospital, Institution or k
Ci , Town or Village D l ' t-(,L�II k Street Address G ic_n 5 Fulls 1-0 5 I
ui
• Manner of Death V( Natural Cause Accident Homicide Suicide Undetermined Pending
ItiT` Circumstances Investigation
at Medical Certifier Name Title
I,t) ilIiawl I C,(a.i fob
//e. 4I2'JUS c\N"/
Death Certificate Filed District Number Reg ter Number
City, Town or Village le f15 )-4) I L 5&,O I /'[)
Wi El Burial Date CAnetery or Crematory
C
❑Entombment I_I tD-LO! 8 ' ` A9 L' ,t;� `Awa I1
Address
ElCremation &twits b t,_ NN/
Date Place Re oved
❑Removal and/or Held
and/Holdor Address
it.,
40
O Date Point of
0 Li Transportation Shipment
E by Common Destination
Carrier
❑Disinterment Date Cemetery Address
il
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M t t I e.r- i( E-}oyAL nog /
' Address
Sys Itti 36 Iy ckaxt Uics NV j2 z-
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
,' Address
cr
in
` Permission is hereby granted to dispose of the human remains described above as ' dicated.
" Date Issued f(4 I 1 8 Registrar of Vital Statistics /0411— -
(signature)
M. District Number :o) ( Place G` f [I S
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k D
III Date of Disposition I/tj I i 3 Place of Disposition ,_/ �c,1-4g..._
(address)
Ili
CC (section) "lot number) c (grave number)
0 Name of Sexton or Person in Charge of Pre ises //%M
(pletise print)
t Signature EI Title (R HIOPt
(over)
DOH-1555 (02/2004)