King, Maria NEW YORK STATE DEPARTMENT OF HEALTH 13
Vital Records Section - Transit Permit
Name
t First Middle. = Last Sex
Date of DeatI Age ") le—
_� g If Vet r)4of U.S. Arme Force J�
w- place of Death 'q War or Dates IVY 0
Hospital, Institution o
iLU(Cit Town or Village lens ( Street Address (� (115 c
a Manner of Death ' ��I � ` ' � �I'� t�G
W @ Natural Cause �Accident 0 Homicide Suicide Undetermined Pending
0 Circumstances Investigation
w Medical Certifier Name Title
Address,
ittel 5 ra I/5
Death Certificate Filed Distrlicf Number Regis Number
>' ('`Cites Town or Village 0 Ley,5 4.ca ft s 5oi
['Burial Date Ce etery or Crematory
❑Entombment 1 _Li ~ i 7 r 1 n e V ! e 1�� 0 t(/y)q i
Address/
MI Cremation `�4 ikC';ey"IStCk ,1
Date J /Place Removed
Z Removal and/or Held
2 and/or Address
F` Hold
O Date Point of
11
❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
IiiI:aQ Reinterment Date Cemetery Address
Permit Issued to Registration Number
MI Name of Funeral Home I .4 i ( kit gA f-1,e if4 f /44001,e-, ;( )9c
<ii Address
Pry 1 Ux 7/ 4 nc i an La.K t_ Ny iZg41
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cr.
Iu
II" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 f L//20 17 Registrar of Vital Statistics CA.. -vim
(signature
igiii District Number 5 b0 f Place G L_Riv‘S Ri, 1 S IQ y
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IIUE Date of Disposition I I L4(1l Place of Disposition Zfivi s,,,, C 2"a N.-
(address)
MI
0
CC (section) (lot number)(` (grave number)
ci Name of Sexton or Person in Charge of premises (4tai j&Aker-
lZplease print
Signature a 2,, Title Cep R31L •
(over)
DOH-1555 (02/2004)