Morris, Ethel c . , # 6-0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First��NQ\ Middle C\ Las ,\ S
Date of Deat r� c-� Age ('� If Veteran of U.S. Armed Forces,
' I i,�Q� 1 "t. War or Dates
Place - Death ttt Hospital, Institution or `
City, Town or Village \OZQCAO Street Address ���'`- 0� �� �
1. Manner of Death M'Natural Cause 0 Accident E Homicide El Suicide 17 Undetermined ri Pending
0 Circumstances Investigation
W Medical Certifier Name7-6\ Title �
Address vb s_t- 5 \w)k Da( ut
Death,Ckrtificate Filed 3 District Number J 1tegist r Number
ow City, n r Village \O tCL'.J y 5(0 2. V o
❑Burial Date 1 t `C[U Ad Cemetery or Crematory's i‘\k., i.CW
ElEntombment Address
Wremation Q ) S\,,, kk-)1
Date JD laceRemoved
Removal and/or Held
and/or Address
E Hold
Date Point of
Ctj Transportation Shipment
i by Common Destination
is, Carrier
11 Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to ,f , \\ Registration Nu ber
Name of Funeral Home Vk �\�(�� 't QAQ-A
Address c<0 ALkCR-�'c\_ 5 . .\-\( CDVQ cam\\c. \\ 1)-c6C)�
Name of Funeral Firm Making Disposition or to Whom I
1_: Remains are Shipped, If Other than Above
Address
A Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7// 10 7 Registrar of Vital Statistics �%eL��
(signature)
District Number tf'St<o 2 Place Tr(✓el df/10 I e4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 'lilt 111 Place of Disposition &,tJ•,--, C'-"- " -'
(address)
O
liL (section) (lot number) (grave number)
Name of Sexton or Person in Charge of PremiseAit,,i So^^"��
ease print)
Signature �� yp Title2
or—
(over)
DOH-1555(02/2004)