LaCourse, Dorothea .._
NEW YORK STATE DEPARTMENT OF HEALTH t . 1 J
Vital Records Section Burial - Transit ermit
Name First Middle La Se w' "(
illillllIli noNa e-a� Pi a_ L-u.4- .
ng Date of Death ' Age If Veteran of U.S, Armed Forc s,
Clkik ` al - �O/ �� War or Dates Qi a
Place o eath Hospital, Institution or
iZ City, ow or Village /IJ 4)C JM-4. Street Address Q
cl Manner of Death grtNatural Cause El Accident E Homicide El Suicide Un eter med —Pending
Circumstances —Investigation
itil Medical Certifier Name J. T
o �"eN ��� A �-_---
t, Address IU_0 A.,,c ` 1. 5..,�„.
Death •� icate Filed District Number G Register Number
City, own Village /l1 QWC,+�»v�- S / /
Date /_a.3 -�/7 C ery orU re toryf�
❑Burial O �Nt- / (�"''' P,�!>��
WC�^� Address .
-Cremation C )e-ekJ 6 v--�
Date / Place Remo�ed
0 — Removal and/or Held
}=
and/or Address
Hold
t
:Q Date Point of
NTransportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
ll El_ Reinterment Date Cemetery Address
'i> Permit Issued to . I Registration Number
ii`'ia Name of Funeral Hom A rd-/ .-ee J/yfowl-A/ (011 _ Uas/9
iiIi tja
l
Addrlia i�
>i. Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
Address
Permission is her by granted to dispose of the human remain
s
described
] ve - dicated.
l Date Issued I -- / Registrar of Vital Statistics (y01A-ix..
(signature)
iiiii
liiIiilil
District Number /5-5-q Place Aiig< c <e Owl L); IV LI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i ZIOLNI
E Date of Disposition I(L3[U7 Place of Disposition air 4-...
2 (address)
ill
N
CC (section) f (lot numb r) (grave number)
9 Name of Sexton or Person in Charge of Pre ises act' L t.tti
(please print)
Signature GC 0 Title `WIY11
(over)
DOH-1555 (9/98)