Orleman, Jeanne 4
NEW YORK STATE DEPARTMENT OF HEALTH "Ail
Vital Records Section Burial - Transit Permit
>;• Name First Middle I ast Sex
3EA1\1n,L" / JAA I a[LE-rplN min
�> /�' Date of Death Age Veteran of U.S.Armed Forces,
Feb. a3 go)7 67 I If War or Dates /V
' P ce of Death ( �-- f Hospital, Institution or
C Town or Village GIe lJS i"A 115 1 Street Address auS 1 is 1-lUS p'h I
in. Manner of Death �I�Natural Cause Accident n Homicide Suicide Undetermined Pending
ILIY Circumstances Investigation
ill Medical Certifier Name Title
C. v il►p,(i r_Ie_Ov(R MD
Address
100 PMt- , JJeNs 14((5 Ki V imle) /
bath Certificate Filed District Numberc� � Register Number is!
. CityyTown or Village (;INN S 5 c�U9�
Burial DateCemetery or Crematory
rre I-7i �.O1`7 Haut \eu) (�Dcrh Y ll70 i
; ;❑Entombment Address
�1Cremation a a►k_n_ P� ®Uc l.Sbu,y a V /awl)
Date I Place Removed
2 C Removal and/or Held
and/or Address
CD Hold
0 Date Point of
.k Transportation Shipment
a by Common Destination
Carrier _
C Disinterment Date Cemetery Address
[�Reinterment Date I Cemetery Address
>: Permit Issued to in ` Registration Number
Name of Funeral Home .0 (2X \-t ;\C{T-AA hDV t- C:1 l 0
Address
- 1 4y
Name of Funeral Firm Making Disposition or to Whom
f - Remains are Shipped, If Other than Above
Address
tr
tit-
Permission is hereby granted to dispose of the human remains describ/ed�abovv as i c) ed.
- Date Issued 'r-�,�j, a'' ri(./1,Registrar of Vital Statistics ��•� J`" toZ ` `-t
!� (signature)
District Number j,o/ Place ei-7i_ NRIL, c/1 (�ie&6 f 1ky /1/k` /°(cl
iI I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition 3/1 111 Place of Disposition emdm..., Gr ifof,,,..-
2 (address)
Ill
th
C. (section) it(lot number) (grave number)
ciName of Sexton or Person in Charge of Pr ises (L i
Z , (pl t se print)
t g
Si nature Lt Title (WAWA
(over)
DOH-1555 (02/2004)