Swan, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit PermitVital Records Section
Name First Middle Last I Sex
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Date of Death i Age I If Veteran of U.S.Armed Forces,
)l /(oil? /CO ( War or Dates •u/✓g-
Place if Hospitals Institution or l
ZCity, own r Village Q 0 d �s d c treet Addre '2 A)0,z nit- p U 2.
ra Manner of Death®Natural Cause ❑A cident El Homicide D Suicide El Undetermined fl Pending
la Circumstances Investigation
La Medical Certifier Name Title
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Address ��
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Death Certificate Filed District Num er Regist$(Number
city, Towr r Village GZ 0 b�,t;�e v 751e 1 137
❑Burial Date / /I Cemetery orremato 11
❑Entombment' I///3 /) ri,uIC Vie--c
Address /�
isk'Cremation Q U oil‘� , a Ul .tkce /
Date " Place Removed ' AY
— Removal and/or Held
and/or Address
U) Hold
O ' Date Point of
Q Transportation Shipment
5 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
ti Permit Issued to l Registration Number
Name of Funeral Home &•Cc_ZC L i-Ne c- \ VADM C. C 11 G
Address
1 r Lc Say - �-�-- �:L ce2,. s\:�.- 1 / \\ 1 2 ,C y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
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• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 t-1-a-011 Registrar of Vital Statistics CSC
(signature)
District Number 5ko 5l. Place Qv Gen S bvij
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
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111.
Date of Disposition (I/win Place of Disposition CW,.,� c'..,...t0-...,
2 (address)
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US
EC (section) A(lot number) ^ (grave number)
ci Name of Sexton or Person in Charge of Premises Lht,4 .- J PM oft
Z // / (Make print)
t Signature ""( ✓ vey Title tp -4140
(over)
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DOH-1555 (02/2004)