Normile, Anne 11i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First A Middle Last Sex r_
i �v S. ivocrm.Z.e.
Date of Death _. Age If Veteran of U.S. Armed Forces,
,44 n 4- 0101 ACV � 7 War or Dates —
14. Pla - of Death �-•� Hospital, Institution or
y gown or Village 6 Ta 1/-- Street Address �Le 71 //\- -s ;
0 *anner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide Nn Undetermined❑Pending
Ut Circumstances Investigation
O.
Medical Certifier Naz„,..0 /1 Title
o � 41 Of�-e4 5..4 (21
Address
Ina Patit4 5t , 6 Lens Ft li,- t Y 1 eo j
Death Certificate Filed !� District Number Register Number
City, Town or Village 4 r FC' J 'I— 331
.DBurial Date .rl- Cemetery or Crematory •
❑Entombment Ju�� 'a" )aol7 i/Ic_V c ,(
Address U
ECremation Cueen\b,>, LtiJ `l+-4 • '
Date 0 / Place Removed
Z❑Removal and/or Held
and/or Address
i" Hold
Cl)
3 Date Point of
hTransportation Shipment
d by Common Destination
Carrier
:.a
0 Disinterment Date Cemetery Address
Date Cemetery Address
3❑Reinterment
Permit Issued to _ Registration Nymber
Name of Funeral Home A .rvIorc_ ��.�cr.! N,.,.t _ peg`�•Y,Y
Address ��_ '
a -4,, A; ((. P Y 1 ), -
> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
lU
Permission is hereby granted to dispose of the human remains descri d above s in . ed.
Date Issued 6/a( 1) Registrar of Vital Statistics / �a" (
7 (signature)
District Number_..s.-6 p( Place •Le-i•-•7 a f i I- t l 7
'.>,: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1�! Date of Disposition (o�ZZ'�'lace of Disposition fouels4 ewnititt ri..`
W (address)
w
cc (section) p/ (lot-number) (grave number)
gName of Sexton or Person in Charge of Pr ises b r�(�"� ►"��6'�
/ (ease pnnt)
ltl Signature �( d" Title 011101
f
(over)
DOH-1555 (02/2004) •