LeFevre, Catherine NEW YORK STATE DEPARTMENT OF HEALTH r , .1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
-rt+EPIklE LE EVRF -'EmaL.E
Date of Death Age If Veteran of U.S. Armed Forces,
—c1L 1 w ,9Z I 1 (0 War or Dates {\I IA
1.4 Pla a of Deaf Hospital, Institution 6r
City, Town er i (.--„,-LE-�c FALLs Street Address (-;�_E,14.5 I L., H DS?1`-l�L-
0 Manner of Deathp. Undetermined Pending
Cause �Accident �Homicide �Suicide �
Ui Circumstances Investigation
iii Medical Certifier Name 811w 2 O Title
V _D
_ _Address / Y IVO . fie 1 d ti -sf vr/Z cry'
Death Certificate Filed -/ District Number ) Register Number
City, Town, or Village Cyr - -CFI L. S 3700/ 3 1 9
::,:i.ii.i D Burial Date \/ 4Crematory A
[]Entombment GI � j-r't I I �l i E- T �( ck [�A u 41ti
Address
i:gqCremation \ U AkE(_ P'V c) 0 EERsEu(t-�) -A 1 a R
Date Place R moved
M El Removal and/or Held
and/or Address
h Hold
t
0 Date Point of
ei Q Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
iiii Permit Issued to Registration Number
`i Name of Funeral Home .. . �-p u NI Fel;L I--c ran c) I rqc , of 1-1-
iigiii Address
9 r r'i .S-r, LAv F. G,-Fr,R 6,) 1 (A i s 4 s'
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
• Address •
I
Ili
Permission is hereby granted to dispose of the human remains des ibed aboveas in ated.
iin
Date Issued' o /Registrar of Vital Statistics „ri� � - �,,4 `"
signature)
ip District Number 6-661 Place C 'YES -PALLS -1 Fc-o ial(_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I�
U• Date of Disposition 1-I�j-II Place of Disposition "I :N dr,.a lvivi rr*--'
(address)
Ill
44
CC (section) A (lot nu er) (grave number)
Name of Sexton or Pers in Charge of remises r vy4 r h N tt
IL C (please print)
41.
Signature Title G MAU L,
(over)
DOH-1555 (02/2004)