Norton, Sherry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
mi Nag 6 r/ty Middle '' /-( Est, Se
ga Date of Death( Age If Veteran of U.S. Armed Forces,
‘,57, 3. / 7 , a. War or Dates
1. Place of Death Hospital, Institution or _—
Citim ,`Town)r Village )--4,,a1.� Street Address 7 1 4; r A Av e—
Manner of Death❑Natural Cause Accident W Homicide 0 Suicide El Undetermined ❑Pending
iti Circumstances Investigation
W Medical Cert fier Name , i - Title
Address
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Death Certificate Filed District Nu car Register Number
City, Town or Village 5- g -J "7 yS- 1
❑Burial Date / Cemetery or Crematory
❑Entombment s ! / �.'�'x'F � �
Address h� I
jKCremation ��!:. -..�_.r�n�1_, '•1rt,
cl
Date f Place Removed
Removal and/or Held
0 and/or Address
i= Hold
U)
0 Date Point of
. ❑Transportation Shipment
a by Common Destination
iiiiiiii Carrier
Disinterment Date Cemetery Address
`< Reinterment Date Cemetery Address
im
Permit Issued to Registration Number
Name of Funeral Home 0-c. S v rr T ki ��_ 6 a y-Y b(
Address 7 erg Av� ) C c. 7L NT i<,.<y?--
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
C
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` Permission is hereby granted to dispose of the human re 'ns described above as indicat
Date Issued Registrar of Vital Statistics � C
c� / 9 4 _ s t� iYt_Ce'l
(signature)
VVVVV District Number `{55-S, Place caa_dy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
tI Date of Disposition 5/i fr Place of Disposition 'i eLL le-.,4 f r.(:.-
a (address)
Cl,in
CC (section) 7; (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises (•ir.,
z (pl ase print)
W. Signature Lam( Title (RIVT r
(over)
DOH-1555 (02/2004)