Ball, Lisa NEW YORK STATE DEPARTMENT OF HEALTH , 105"
Vital Records Section Burial - Transit Permit
Name irst Middle ast Se
c.
Da e f Deathtge'Le
If Veteran of U.S. Armed Forces,
I / Q1 /J) War or Dates no
1-- Place o eath Hospital, Institution or
ii City, own orillag lS � Street Address
O Mann of Death Natural Cause c€ci ent Homicide ❑Suicide Undetermined Pending
W ❑��`-� Circumstances Investigation
0 g
lU Medical Certifier ame Titl
z 11 « c,-, c S
Address
1C_ t C ; a 0,01
Death ert+ ate Filed District NumberF 0eni r Number
City, own o illage ( laJ2a-nS ( v.\--
ffl 0 Burial Da etery or Crematory
;:❑E::at:
bt Address ( ( '
0 CA-\C 2? )�j V..,. 0...1.4.Q.32..-- ,� \,� ,...
Date Place Removed
❑Removal and/or HeldC...._)
and/or
F Address
Hold
0 Date Point of
iTransportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home ,� -"'`' - -- � ', �� -� , \ -\L\
Address
Name of Funeral Firm Making Disposition or to Whom
.i Remains are Shipped, If Other than Above
• Address
#r
IU
7" Permission is hereby granted to dispose of the human refrains described above a4 indicated.
Date Issued 1 ( �, ll Registrar of Vital Statistics
b (signature)
District Number (o � Place 1 ,_`� �'
::_. I certify that the remains of the decedent identified above were disposed of in acc dance with t "s permit on:
ILI Date of Disposition ;Ji, I if Place of Disposition 1)...4 «,„t .j...,..
(address)
ill
MI
CC (section) 4 (lot number) ( - (grave number)
Ct
el Name of Sexton or Person in Charge of Pr mises r,. J c..'tt
( ease print)
• Signature G" V i htM .-
g Title n4'�
(over)
DOH-1555 (02/2004)