Radecki, Faye h. 70 Z
NEW YORK STATE DEPARTMENT OF HEALTH d ) p
Vital Records Section . Bur' ,l - Transit Permit
Name First ii--' MMM� f)le last Sex �r-.
Date of Death Age If Veteran of U.S. Armed Foi
• 7/L/17 '1 War or Dates
}_ Place of Death Hospital, Institution ozTh
Z City, n r Village ie r,',t� Street Address 1 . ,--a�-
O Man Death 4i Natural Cause 0 Accident 0 Homicide C Suicide u C }determined 0 Pending
U Circumstances Investigation
CI Medical Certifier Name), Title
Address
1l iv RA, �;L—]v, , Nr Th )i
Death icate Filed /"' _District Number Register Number
City. n Village fi.' ,_ Lf5-S �
Date Cemetery or Ore ' y
Burial
1/ao (a.0/7 ► ;i`, V'c,-..) ( ^',
Address 7' 1
Cremation / of
Date (� Place Removed i
•
Z Removal `�O and/or Held
i-
F- and/or Address
- Hold
0 Date Point of
1 Transportation Shipment
Ea by Common Destination
Carrier
7 Disinterment Date Cemetery Address
Reinterment Date • Cemetery Address
Permit Issued to , Registration Number
Name of Funeral Horn �"s,,,rc t...�c.r. C f7.wI -1--c_ 0°
Address
7 _. ern., A C y r-'c jJ( l &aY
• Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
Address
i
Permission Is hereby granted to dispose of the human r.•• ••=scribed ov: - •{cated.
• Date Issued / Ristrar of Vital Statistics _�° 7/7 'inn-,a •re) .
District Number I17 Place ��. '` -/ /V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition gIZ2 f 10 Place of Disposition bb ,,,..e,b—
: ..., .. . (address)
w
cc (section) number . (grave number)
O Name of Sexton or Person in Charge of Premises ti(lat
i,M^<` "
(please print) {.
ItA
w Signature �i ., Title ;04fi
vS-61.
DOH 1555 (10/89) p. 1 of 2