Slimmer, Bridanna NEW YORK STATE DEPARTMENT OF HEALTH + A 'AO
Vital Records Section Burial - Transit Permit
Name F t iddle I Last Sex F, I,rIA�nA � St 4. ssic2
Date of Death Age If Veteran of U.S. Armed Forces,
l)/ a . /)�r7 i 5 War or Dates
Place of Death Hospital. Institution or ,
'Z City. Town •� '.ilia•) Ior.x - Street Address 1f /t t' CA--
AManner of D =-- AI Natural Cause Accident 0 Homicide 0 Suicide Undetermined —Pending
t,I, Circumstances —"'Investigation
'P Medical Certifier Name" Title
�~ Addre�sj
J4frety }-1's 6.4/1.,,.rv� 5�4.+0 ti r I_ 16� l
Death Certifela - -•, J / Districmb c' Register Number
. .City, Town •- ` C� t' Jam✓ ,
sate Ceme y or rematory
n
t !Burial 1\/1colhao/7 ',✓►e Vie_ L,. C—fcn.l4iI 'Address `�
XCremation Neo S b.1i K) II
• Date Place Removed
I Removal and/or Held
O and/or Address
I Hold •
O Date Point of
Cl.;• Transportation Shipment
E by Common Destination .
Carrier
Disinterment Date Cemetery Address
C Reinterment Date Cemetery Address
Permit Issued to 1�—� ' +t--� _ Registration Number
m -Name of Funeral Hoe 5"`,.o K / a&r,/ "'v � 1r. Oo '7 4
Address �
7 6AetMaq Ave- C or, ki Y i: --
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
Permission is hereby ranted to dispose of the human r: - = •:scribed ov- •icated.
iii
>` Date Issued II ,,)1i f Registrar of Vital Statistics Ago , 2 -
.•a Are) ,
Place r ,- , �w /o r / 1
District NumberL/-S � {
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition I! In Ill Place of Disposition fKt)---/ A p..--
M (address)
w
C (section) A/ (l r(lot numb (grave number)
.• Name of Sexton or Person in Charge of Pre ises l nn�- i,,,tbfi
z (please print) /
W Signature Title AZ.MR fr,
OOH-1555 (10/89) p. 1 of 2 vS-61