Wood, Betty NEW YORK STATE DEPARTMENT OF HEALTH Z�3
Vital Records Section L:,uria11 _ Transit Permit
Name First Midd r Last ( � (�j� 4 Sex / I
.:.,•,.,:,,
..
<_. Date of Deaths 1 d f I Ag 2 I f Veteran of U.S.Armed Forces,
�1 Z p i ` i War or Date
F; Place of Deat I Hospital, stitutlo or
City, Town o Village- ''O�(� � U Street Ad. (t Ii W a Soya _
in Manner of D=. • zrA Natural Cause 0 Accident ❑Homicide 0 Suicide 0 Undetermined fl Pending
W ! Circumstances Investigation
LI Medical Certifier Name Title
r rN\ 1‘ v J - (ilk( Ol. Ti .
Address
z Death Certificate -d ,^' I( District Nu ber Register Number
} - r-'t- Eawctrd
City,Town or illag- —r ft II
V�OXC ! ���� 15
Burial sate n 2 iilc Cemetery o re atory ,� n
,; Q Entombment Address Y uC
I ►. remation U a Q.kAkeikS bi1 Ni 4
Date I Place Removed I
—Removal ! and/or Held
—and/or Address
i
Hold
Date Point of
Q Transportation Shipment
by Common I Destination
Carrier i
Li Disinterment Date Cemetery Address
A!E Reinterment I Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home . \-: � ��,�L, t \ het `�1 I �ii „�.. "� "�
C
Address _ _
-f. .44-...� 1 ,�.�"T �- :.i...-c-2 l Vl:. `i ! 1�� lZ�li i
E. Name of Funeral Firm Making Disposition or to Whom l
1 Remains are Shipped, If Other than Above
• Address ,p
EC
i.
Permission is ereb granted to dispose of the hu ins descri e o indicated.
Date Issued 3 Registrar of Vital Statistics Y '
(signature)
District Number 6-165 Place'— , (q6 UOC� ��V//
`;>>. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-� a
iTi Date of Disposition , J3 in Place of Disposition Rnc Ultsf >!r ,4-or ivv..
LDf (address)
= (section) ,/ (lot number) (grave number)
o
Name of Sexton or Person in Charge of Premises (Ar1i� hir J¢,a N�F
z (plf ase print)
Signature M .. Title f11E1Y1 MDet
(over)
-
DOH-1555 (02/2004)