Starb, Eleanor t 1 # 16
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - T ansit Permit
F.< Name First Middi Last Sex.-
11Date of Death Age If Veteran of U.S.Armed Forces,
27 /? A War or Dates
rg
t-
Place th Hos•�t r: i. titution or � �%
: Ci Town Village( U eLr�s Q [
Street Address / t -c.N��3
Manner of th�Naturai Cause a Accent ❑Homicide 0 Suicide D Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0-L, e-(Li. t_ C.) d--- A /
Address f` ,
11 — &-r-L-r7 S'S--' C Cc-,-,..
" Death cate Filed Dis Nu R-•ister ,umber
C' Towner Village C k S,--)3 (cis
Date Cemetery or Crematory f
E,Burial / 3 S 42 ((( , V;,' /6-1-‘-)
Address .
F3Cremation �"I(,EN i 0.2 �-"af' C� ;, /f.Z
Date Place Removed
' a Removal and/or Held
�, and/or Address
ri Hold
4*. Date Point of
R:0 Transportation j Shipment
by Common Destination
Carrier •
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home He. Hard v` 'Baker Funeral Horne_ •(13C3
Address
14 11 Lafa.-j tC of. , &uPePSb .rti,I(lU_v LVVA- laA)/
Name of Funeral Firm Making Disposition or to Whom
."-;; Remains are Shipped, If Other than Above
Address
Yy
S a
tl Permission is herebygranted to dispose of the human ains described b e as indicated.
Date Issued f 1?O i 7 Registrar of Vital Statistics �_Q /1-&---'W (signan
District Number tZcl Place i d�(...o- -- ,(
I certify that the remains of the decedent identified above were disposed of in. F••rdance with 1 is permit on:
Date of Disposition Z(t I I/ Place of Disposition 40..✓ r toff...,
(address)
lLl
„i (section) /f(iot number. (grave number)
flName of Sexton or Person in Charge f Premises [iq wilt'
g (please print) /
Signature L[ P--
Title (R t
(over)
DOH-1555 (9/98)