Smith, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial = Transit Permit
Name First ai,
\ \S;ifif Middle LastSok:i 1 Akalx Sex /"
Date of Death Ageg If Veteran of U.S. Armed Forces,
IN / 1 2_ War .r Dates
P - e of Death _r r ospita0 Institution or
Town or Village (derOc - .1 I SILI eet Address -e ' ��S
0 V anner of DeatN Natural Cause El Accident Homicide E Suicide Undetermined El Pending
Circumstances Investigation
tu Medical Certifier Name � Title
&)-ri CZ Vi L f (—, / l
Address pnit
S
/0 Z J . Elul J itJ , s7
oath Certificate Filed L1 fu C HS District Numbe ue 1 RegisteAn
Town or Village J
►; curial � Date � � ,,,
�
Entombment Address } meterOrema /�� ��1�n�/L�` �nn1
:_ ❑Cremation SC L\1 1 v l C K /V _
:'`' Date Pace Removed
Zr—Removal and/or Held
and/or Address
Hold
fp
0 Date Point of
❑Transportation Shipment
:ct by Common Destination
Carrier
Q Disinterment Date Cemetery Address
igi 0 Reinterment Date I Cemetery Address
Permit Issued to ' Registration Number
Name of Funeral Home tiL C ,1e.;- \ ho cn , CAI I "?-0
Address _
\' Lc.:,, -1/4`I f\\�- -,� - _ 1 R y e Lk
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
. Permission is hereby granted to dispose of the human re ains described above ind cated.
Date Issued 0, / _,�/5 �O/7 Registrar of Vital Statistics , , ? < �(signature)
District Number 6,6,( Place �� n r ,2 `�`
I certify that the remains of the decedent identified above were disposed of in accord ce with this permit on:
J( Date of Disposition S/ J,j 7 Place of Disposition 1 L). ire,yet c''V
2 (address)
al
i -
(section) (11 number) (grave number)
CI
Name of Sexton or rho . Charge of Premises -Iµ I i4..-t [JG.. cLc-h e
z (please print)
PA ...______...._.
Signature f �;� Title fa mac.�d
(over)
DOH-1555 (02/2004)