Slingerland, Annie ,
NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section Burial - Transit Permit
-? Name First i9icile Last Sex
v. ,J/L C.l 0,-- �L.).,.t c 0,..._Urea .17:6 7 r9Z tr.
F';: Date of Deat Age If Veteran of U.S.Armed Forces,
�`'` 3/Z� /7 3 Z. War or Dates ,3'K9
Places ath � b tution or
Ci ,Town r Village l �1 u ,j ( U 2 Street Address ) 2.. 1 IR Oo i 4 ci 120,
liLl
0 Manner of Death Q Natural Cause 0 Ac dent Homicide 0 Suicide C Undetermined EN Pending
ID Circumstances nvestigation
ill Medical Certifier Name - Title
CZ MiCA,V1 cS, lifeie4 NID-
Address r'
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Death certificate Filed Q i�cte ber egiister Number
Cit(Tow r Village U `Ls�1 S e U 2,t., ? �� G
<•DBurial Date Cemetery ►r Crematory
: `[]Entombment Address Z? }� 1 (� c' (I16'-J
emation U 6"7e1. i y ^ t&e..cl fS (,�Y[�L Af7
Date Place Removed /
n Removal and/or Held
and/or Address
U 3 Hold
O Date Point of
Transportation�} ❑ P Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
„> �]Reinterment Date Cemetery Address
Permit issued to � Registration Number
Name of Funeral Home 1):ViL FC,C.\ecr \ hp l- C-11 :-,0
Address r. -
Name of Funeral Firm Making Disposition or to Whom
14. Remains are Shipped, If Other than Above
• Address
ILI
Permission is hereby granted to dispose of the human re i s described abov as indicated.
Date Issued
4;;3---1 i t? Registrar of Vital Statistics q, nti_
—..„ (signature)District Numbers( --) Place 0 Ct-r-1 c3-( C LDS I�IJ_
-,, I certify that the remains of the decedent identified above were disposed of in ac ordance ith this permit on:
I
W Date of Disposition 3f7-$J+1 Place of Disposition .PM14Ucw C _ `�
2 (address) r
tzDC (section) i/(!ot number) (grave number)
Name of Sexton or Person in Charge Premises t A r f t wt l
(plea a print)
Signature l� Title fti1Y C
(over)
DOH-I555 (02/2004)