Towers, Norma NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section . Burial - Transit Permit
II Name First Middle✓ Las Sex
/UO r-Pi t. I' MO)-P CS
iil Date of Death 7 Age If Veteran of U.S. Armed Forces,
/'a-9_ /7 O C 9 War or Dates J 0
..'.... Place of Death 7 C' / 5 f" Hospital, Institution or
City, Town or Village 'Axe 1-02_e_r/-) Street Address o1.a37 C.--.-t c4---
Manner of Death ui( Natural Cause 1=IAccident El Homicide El Suicide El Undetermined ri Pending
Circumstances Investigation
II Medical Certifier Name,_ Title
/Aik
Address
601 4In,ck- Avti (.; r. , IQ 'f 1),5D-1____
"1 Death Certificate Filed District Number �— Register Number
diii City, Town or Village LA k2 L )2 e2/?
Date Ce tery or Crematory ,-
ii: ElBurial %- 30 ' c /,7 P/'i'11✓!'e kJ C..,C eM&`l'u-6/
Address
>` ®Cremation r r2 6- cu y
Date Place Removed
0�Removal and/or Held
and/or Address
a Hold
0 Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
:: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
P j� 16,:e Registration Number
Nameermit ofIssuedFuneralto Home �/O 7 ; Y� 0 /CL� �� , 0 v"ty-SJ
r Address Axe__ -,. ,/,--/w7(/-7 ,
/0/ /dis--- - -)._
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ig Permission is hereby granted to dispose of the hums e .ains de ribedl r e as indicated.
E"3
ftS�Date Issued ���`o�C�l 7 Registrar of Vital Statistic lam •
_cre.,, ��P .c.r?'l,'L
( nature)
iiiid District Number 3OSZ Place La He "./,( ,�
I certify that the remains of the decedent identified above '- disposed of in accordance with this permit on:
F p (�
E Date of Disposition Z( I /I Place of Disposition 4 utJ ../ Cry► it'rt'_
2 (address)
w
Ca
CC (section) /A/Ql�-otIi number) (grave number)
G Name of Sexton or Person in Charge of P emises C r,*.it-
(please S4oif�
g print) "�
W Signature Li c Title C V Att.
(over)
DOH-1555 (9/98) .