Wright, Susan E NEW YORK STATE DEPARTMENT OF HEALTH P lob 1
Vital Records Section '''" Burial - Transit Permit/07(
li Name First Middle .Last Se
N.` Date of Death. Age If Veteran of U.S. ed orces,
el .
` � I 7? f /e, 9 "70 War or Dates _._,.
Place of Death �- Hospital, Institution or
City, Town • Villa.- C, r"TC Street Address I r 1t!I Ave".. .
!i Manner of - ® Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
il Medical Certifier Name — Title
,),L
:fig
ri KL1 M
a Address
itio
c-r(� oe /!-4 , µ'/`f, G ills ", sA, N 7 tarn �
Death Certificate Filed C (7 District Number Ss Register Number
ge City, Town or�� .•- �' " a,v
Date , j Cemetery or matory
❑Burial i, /,.j / �' ,`,,,c„' c w C`c :-2 o
Address [/
•`:: L1J Cremation Q -L t,,.s y tA r tJ 7 .
Date J " Place Removed
O❑Removal and/or Held
-.• and/or Address
a Hold
9 Date Point of
18❑Transportation Shipment
a by Common Destination
Carrier
':• ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
;<k: Permit Issued to Registration Number
Name of Funeral Home-TN Registration
FikiNec .\ \--or . .1.+(1C. 00LI4%
al; Address 1 S^ ^rma.n eOrk n N`I 1 $a;g,
�'i] Name of Funeral FirmMaking Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iiiIii Permission is hereby granted to dispose of the human mains des ribed a ove indicated.
:v :: Date Issued 9 talkaeao Registrar of Vital Statistics a - fu o
(signature)
tel C- Place 1 CLOn cyc e )fi n-V 1 N N' District Number y J�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i /'
E Date of Disposition J0/1/zo �i.Place of Disposition _11 (�-If`-
2 (address)
W .
CA
1C (section) (lo um er) (grave number)
Name of Sexton or Person in Char a of PremisCI s1t L 3.1,14 if
Z (please print)
W Signature Title ( '''t11(4-
(over)
DOH-1555 (9/98)
Public Health Law Sec. 4145(2b) 0 1 4 0 6 2
Receipt
Human remains of delivered on ' , 20
Pine View Cemetery Representing the funeral home named on hurial permit
Official Funeral Directors Reg.or License#