Swallow, Jennifer Say
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
:,, Name First Middle I act I Sex
J 1`vve r �a SI�v I I d w -
E= Date of Death Age If Veteran of U.S. Armed Forces,
�' 1 l I ( -4- ` 4 (0 I War or Dates
-tom e of Death Hos • Institution or �/
CitIlly Town or Village C in S -1-(,t // Street Addre 20Q(�)/G_N AV-Q,•
CI anner of Death Natural Cause 0 Accident Homicide D Suicide ri Undetermined ri Q Pending
Circumstances Investigation
j Medical Certifier Name Title
Q -r►PI o$ int pAtii ( (-) ro n '
Address s 2 /la Vi /a/i4 l/t-e-•1 t 1e 7 s Il5 /Z8o
Death Certificate Filed /\ i f I District Number Register N bar0Town or Village (, s 0 3
>- ■Burial 1 Date T/ 1Z // 4 1 Cemetery o remato ) p
❑Entombment Address ,,// ( ll p�iv7
Cremation ()11l Livr rd , 44.kcY y, A\I i20 o `7
Date Place Removed
Z❑Removal and/or Held
and/or Address
td}
Hold 1
gi ( Date I Point of
❑Transportation Shipment
by Common Destination
Carrier
Q Disinterment 1 Date 1 Cemetery Address
:;Q Reinterment I Date 1 Cemetery Address
Permit Issued to 1 Registration Number
Name of Funeral Home t 'hC� �i.';- e i\ hD-rcl t ` C. 11 C.
Address ,,,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ir
w
Permission is hereby granted to dispose of the human remains described above,as" "cated.
Date Issued _ ? Jr 2-/2017 Registrar of Vital Statistics \CAA,
(signatu a)
District Number 5 l`�� j Place 6 'c 1 1 S j iv y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Place of Disposition , VA", 0rti
l�l Date of Disposition 7(ly�n ' �
2 (address)
la
VI (section) (lot number) r- (9 rave number)
ptr
O.
Name of Sexton or Person in Charge of Premises 6 n Si '' ✓z'"Af
pleas print)
bs Signature ., Title (REPA-1--
(over)
DOH-1555 (02/2004)