Traynor, Shirley NEW YORK STATE DEPARTMENT OF HEALTH _ i # !f((
Vital Records Section ,, ��
Burial - Transit Permit
Name First Middle Last Sex
Sh i rlej Tea v n orerr)alC
Di Date of
Death Age If Veteran of U.S. Armed Forces,
Co- rip i---7 KS W or Dates ,(\)D
1 Place of Death H restitution or
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City(Tow�r or Village L -2 nc Lo St / ss )3(04 T� Rd
t Manner of Death r Natural Cause ❑Accident ❑rr=..nir 1 Suicide ❑Un!ie et rmined Pending
IL Circumstances Investigation
til Medical Certifier. Name itle"
0 �u.5Sel( ta cx NA
Address
LC) v�q �
Death Certificate File U1 District Number Register Number
City(Tow or Village Lon c L z-(0
❑Burial Date 1 1 etery'gr Crei atory
❑Entombment (I)`s ,3 d�, /1 ' n� Y 1 e i�-
Ad
[,Cremation I,,,_Q-e
Date Place Removed
Z Removal and/or Held
2❑and/or Address
f= Hold
i
0 Date Point of
CL
❑Transportation Shipment
C5 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home AAL t i t r ) J12 yy ,, a/ l 11
>: Address
> ko ----) MA at 0 )y)citaft 1-al--e lity izgti
< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
to
Permission is hereby granted to dispose of the human re Rains described above as indicated.
Date Issued (o Z Z -, Registrar of Vital Statistics /6 G o 6t4
(signature)
District Number 6/96‘2 Place ' 0 tor) q i
DI Li:Lice__
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-,
P
I Date of Disposition (D/ 3Jf Place of Disposition _ fine r,✓ Ls +/•"-
2 (address)
LEE
tO
C (section) /', (lot number) (grave number)
ilt
Name of Sexton or Person in Charge of Premises
4 /+P�siv! ��'►1
z ,,�� (pl ase print)
Signature LL s Title itemfj
(over)
DOH-1555 (02/2004)