Albert, Wanda if go
NEW YORK STATE DEPARTMENT OF HEALT1t
Vital Records Section Burial - Transit Permit
Name First) &� Middle List axe/141,`
Date of ueatn Age If Veteran of U.S. Armed Forces,
-10 War or Dates k f b
i-- Place of Death �- � Hospital, Instituti nor "
iijCity, Town or Village ��(J�r"� Street Address 0 kii t(0-
0 Manner of Death I..Natural Cause I=1 Accident El Homicide Ei Suicide 17 Undetermined ri Pending
Circumstances Investigation
tint Medical Certifier it
3-ova` cass (' oto (Y kyi
1-29)0 `
ii Death Certificate Filed District Number Register Number tif
City, Town or Village J r�
❑Burial Date i 2� ( 7tpry or Ctrs c ry
❑Entombment Addre
D,remation Wwssoth
Date Place Removed
Removal and/or Held
and/or Address
M= Hold
CO
0 Date Point of
DiEl Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ,i k\MQ_c 0107 q
HI Address Ba yxcir* -± OR,opz..L
kkiV aD5
iiiiil Name of Funeral Firm Making Disp ition or to Whom
14. Remains are Shipped, If Other than Above
a Address
2
it
` Permission is h r ranted to dispose of the hums r 'ns described ab ve as' dicated.
MI Date Issued Registrar of Vital Statistics
1-1 (signature)
iiRii! District Number 5-1 55 Place 1 c-W6 'r V `_-L �dai' d
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k lif Date of Disposition /1 24 i IQ Place of Disposition 1 p
I/--- 4•-r t,----
la (address)
to
IC (section) 4,,,l _
(let number r (grave number)
a
Name of Sexton or Person in Charge of remises �-��ti
please print
iLi
IPm
: Signature Title ! 91--
(over)
DOH-1555 (02/2004)