Schlmeyer, Jeanne 1E —135
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle_ Last Sex
t,. Date of Death Age , If Veteran of S. Armed Forces,
0- 3 -- .-OC, i l 2 War or Dates fij 0
Place eath Hospital, Institution o � ` �,
c- Cit Town r Village f"ui (et/ Street Address I W o, '1� . �j 1
-• Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier NTT �" , Title
--e—d\Sz -ili�C s V\Ci C�l 1(z l
CAddr s
O r i r\l-11
kg Death Certificate Filed r District im r Register Number
• City, Town or Village I-4(t' (t'V) t50
tz❑Burial Date al I etery or Crema ry�p ���?[�
[I Entombment
I D - L( — 11 r tl i.4`GO, _ 'cYli `"' - (Ur
Address
Cremation G(,t Ai buca ski Date Plae Rem ved
Removal and/or Held
• and/or Address
Hold
Date Point of
❑Transportation Shipment
,-- by Common Destination
Carrier
• Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home 3—CLJ. -er - j L j ZYfli.t I Y)C Coo;..{i
zii.:- Address 0.4_
akr- i1 ,5+ c_ 1 )2 -m !y iZ-gli-)
711 Name of Funeral Firm Making Disposition or to Whom
;KKK Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human ,remains described above as indica d.
-- Date Issued ( 0 -I ' 3 Registrar of Vital Statistics %C }�,jie Q (-->--7 �
(signature)
rac District Number c/ ✓ Place TIT,�u�� 1Q(j1a
inaccordance with this permit on:
ka I certify that the remains of the decedent identified above were disposed of
Date of Disposition fU-S-/7 Place of Disposition 2, i, t JJ 6,r , r
(address)/
(section) lot number) (grave number)
45.
1' Name of Sexton or P rson i Charge of Premises 3�-1 i 1 64444 4.��
(please print)
46 Signature Title G re.4-r —..
(over)
DOH-1555 (02/2004)