Wood, Diane _ I
NEW YORK STATE DEPARTMENT OF HEALTH 1-0 d
Vital Records Section Burial ® Transit Permit
Name Firs MiddleAA Middle fln fit' Last ' rood Sex-F
iyg
Date of Death uIGI f A e I IIf'Vt Veteran of U.S. Armed Forces,I I / .3 + War or Dates
�a of Death 6 Ie ti.S 7Z�1.I I J '�"'pitallttstitution or 1 O Tar
� �� 1�+ , Town or Village ', 'lam Street Address1 _
la Manner of DeatLlt h Natural Cause Accident Homicide D Suicide Undetermined Pending
Circumstances investigation
ill Medical Certifier Name Title M
0 / vd 61,t..cf i�U�"ri_i / ` .l
Address
I(.) e iii.ovv-\ , ,
� >E t�i Certificate Filed I
District Number ��� ( Register Number j� )
Cit wn or Village L-r.J S / 'fit .
❑BUr1aI Date 31; b /( � Cemetery o 'mato ` . ,j
Entombment t V
��,r Address 1 t� - l_ h 1�f (�
Cremation a J�-��Q (2-Va_d j 040.:; -e,A, J iA- , ) `i t - b
Date Place Removed
C Removal and/or Held
.2 and/or Address
E Hold
.e Date Point of
E Transportation Shipment
5 by Common Destination
Carrier
I t Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
%:: Permit Issued to 7 Registration Number
Name of Funeral Home t .' ya t-" ;:;1L(i \ ho“"1 t )t\ ;,G
Address r -
1 t t_._e ,{ L.\-. art c::_`:�\ 1 1 Ky 1-2-e y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
re
I liI
S Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/ / 0 it 7 Registrar of Vital Statistics {i..)Qki\dy,-
(signature
iiZ District Number Cj (r O ) Place 6 (a„,,c 1 \\c P;J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ili Date of Disposition 3//3J/ 7 Place of Disposition J i h u,`�, C-i_e,,-�r,-,. eci
/ (address) /
ILI
til
C (section) (lot number) (grave number)
0 Name of Sexton or r e,"in Charge of Premises -J i.-. 1 i v7 6e,,j r i 4- -4 e
yj0 (please print)
Signature Title C-/Q-Ire--Irf '
(over)
-
DOH-1555 (02/2004)