Towers, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH'., # ,/
• Vital Records Section �, Burial..- Transit Permit
" Name First
3f Middle �.s�'� Sex t
Date of.Death., .., Age. . If Veteran of`Li S. Armed Forces,
f /0)- z
t7 -1, ,War or Dates
- A PI- - of Death -- -Hospital, Institution or
•wn or:Villaa 6� ,J.
g � � -- Street Address
� r of Death 171
xi Natural Cause []Accident 0 Homicide 0 Suicide El Undetermined Pending
Circumstances Investigation
cal Medical Certifier Name Title
Address , V _
":, /l,'a r•f. ) (9 `e 4( &! `( l'D �'f
Mi D-- Certificate Filed District Number Register N ber
>sl own or Village C 4. - a----- S-&6( 9 ',.)L 10
Pi liBurial , Date•::: •Cemetery or Crematory •
' �,`
❑Entombment ,.Address . . . . • . ,
4 [Cremation , . 0 <x e rs 6-�r / A16..,, ei.� —.r/L _ •
�f. •: : -Date % - ; Place Removed
Z Removal and/or Held
0 a and/or Address
f
Hold
Date Point of
L]Transportation • Shipment '
'"' by Common Destination
x; Carrier
r` Date Cemetery Address
'" L i Disinterment
,;; 0 Reinterinent
Date Cemetery Address
• %r1 Permit Issued to -- Registration N um r
• f"; Name of Funeral Ho I v�Crc d- . a 0'
Address -' -
m ef,� �-v-e 6 i, /v 7 /2c)-z__.-.
/
Name of Funeral Firm Making'Disposition or to Whom
Remains are Shipped, If Other than Above
. 2 Address ,
•
Permission is hereby granted to dispose.of the human remains descri d above s in ed.
is Date Issued & / Registrar of Vital Statistics
<..;., r^ (signature)
/,•• District Number c(g c/ Place �4a.4Lf--r.A. I (, ) fJ tr
f
'6.r' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 54tt►f►) Place of Disposition g� �'v ' C �i�. •
(address)
(section)In
number) (grave number)
rr (lot
• II Name of Sexton or Person in Charge f Premises !�•`s �- �����
A - 7' (plese print)
'` Signature j.� Title ik 'ic{Terk
�:r
(over)
DOH-1555 (02/2004)