Walkup, Irene • . , il 1 1 g
NEW YORK STATE DEPARTMENT OF HEALTH . . .
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex.--
Date of Death 1 Age cor\ , If Veteran of U.S. Armed Forces,
CItr.1 ! ....) i War or Dates...
1.... Place of Death Hospital, Institution or
Z City, Town or ,f illaii,..! S (-4` -9-- 5f-Cc""\---" 1 Street Address ! !
Manner o Deathr0
f .....
Natural Cause Ell Accident E Homicide E Suicide
0 Undetermined ri Pending
LU Circumstances "Investigation
0 -
la Medical Certifier ?Tame Title
0 _IVIN
Address
Death Certificate Filed ,-., i District Number I Registim Number
• City, Town or Village -301<.),\Nr .Gtey\-5--c- _CiA), 1
C:1/3urial Date ct(25 (4)..(3n 1 Cemetery or Creffiatory•
i ?Mk.\)•<--"! _R-tsix03.\(:n
DEntornbment! .J.
Address
remation ' L-•-•\tL-3(:24\c3\p' .1 \k . .
V ....
Date i Place Removed
gri Removal and/or Held
§ 'and/or Address
Hold
g
0 Transportation
Date Point of
i Shipment
is by Common Destination
Carrier
r 1
I Cemetery Address
• ' 'Disinterment Date
-- „ •
Date 1, Cemetery Address
0 Reinterment
—
Permit Issued to i Regi§tration Number
• Name ot Funeral Home *V-V- 3 \t-- .\\cN.Q.S.--- • -•\"\-- I C)\b-1,Ck Address
Name of Funeral Firm Making Dispositi or to Whom
tz Remains are Shipped, If Other than Above
-
ZE Address
tc
• Permission is hereby granted to dispose of the human re • , . described above indicated,
Date Issued 9 / g s i 1-7 Registrar of Vital Statistics AL, -'' " , )ae--1--(
(signature)
, District Number 41 5a Li Place Nd4 6/ef?5 ,.-1-7..0
4... I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k ,
141 Date of Disposition <07:Il(/Place of Disposition
2, (address)
Lif
fn
15 (sectIon) /yat number) r, (grave number)
el Name of Sexton or Person in Charge of Premiss14 AIL 3;4,44
z (pie so print)
41 Signature N Title net Thietrk
(over)
DOH-1555 (02/2004)