Lockwood, Heather NEW YORK STATE DEPARTMENT OF HEALTH It 3(40
Vital Records Section N Burial - Transit Permit
Name First 0 Middle,— Last Sex
F•/A t� �,� LCkwoo1
_., ;` ii Date of Death Age If Veteran of U.S. Armed Forces,
Q 5-of ='7,017 q War or Dates ,
14 Place of Death Hospital, Institution or
ity, T n or Village A �g v Street Address 42, .ty I i O 1 CAi__
f Deathatural Cause Accident Homicide Suicide Undetermined Pending
LEE Circumstances Investigation
10
til Medical Certifier Na n Title
>4 1Nore-i') f;Di N o-r! ��
Ad r, s
ik) (A) 3C-071-A30 Pkkoe, A LB/1/40" NY L-2--2-06) _
'!; '-ath Certificate Filed ADistrict Number Register Number
`i a own or Village 1- v _
■Burial Date _ Gmetery or cremato
❑E mbrnent OS—Qr=ZUt/ Na v 1 e i'tiA'Ivi�Y
Address /�-� 12 P=fiasi3' )� A , / ti
Cremation Z� LY V��(�1��- Q V 'V �Z�D
Date Place Removed
Removal and/or Held
and/or Address
i= Hold
CA
0 Date Point of
i; 0 Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
<j Reinterment Date Cemetery Address
Permit Issued to �� Registration Number
Name of Funeral Home .6, V\l LIM—rV} RAz IVo M 1� 10-7e
Address 13t:, Pik /J S ., IOL Q s S PJ I'263
gli Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
it
t
Permission is hereby granted to dispose of the human - , •escribe., abo - a- ndicatl7.
Date Issued 0.5'0"1-20/7 Registrar of Vital Statistics /
(signature)
District Number 101 Place 0 t -r,t o f AL.ca„„,y1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 51 it 1 n Place of Disposition "Frig,,./ 401-4/
2 (address)
in
in
re (section) 4/(lot number) (grave number)
Ck
Name of Sexton or Person in Charge of Premises (At r s.IUtt
"!► (pl ase print)
44
Signature TLitle CREMf3iUa--
(over)
DOH-1555 (02/2004)