Loading...
Young, Janis If NEW YORK STATE DEPARTMEh.r OF HEALTH` ' " ` b Vital Records Section i Burial - Transit Permit, Name.,First Middle Last Sex ,n1S 7 You nq le Date of Death Age If Veteran of U. Armed Forces, ia— -7© I 1 7g War or Dates r)p }•- Place of Death Hospital, Institution or r City Town or Villagel�j le.l')5 Gas Street Address ��S N5 f 1 C Manner of Death Natural Cause ❑Accident Homicide Suicide ❑Undetermin d Pending tl Circumstances Investigation til Medical Certifier Name Title 14. hr-e K Sm ►'fh M D Address G6 5 tis -DSp lk& 1 Death Certificate File District Number Regis/pr ;';''City)Town or Village l. tens Pa[t 560 1 9 .;! Burial Datea1_ 1 ete or Cre atory n e V( Lt-e vna`1D " ❑Entombment Addr YY ; ]Cremation L s n5 b U Iv1 Y Date J Place Removed Z❑Removal and/or Held P. and/or Address I: Hold {? Date Point of fl" Transportation Shipment 0 by Common Destination iiii Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address ig Permit Issued to Registration Number Name of Funeral Home' tu3er -h Q I --krnp i 1 /)c_ 0061 11 Addresses Chu,rc h S . .) Po oocapo [ a f<e. Luz --ne7 k)Y id 0L/ 0 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address ill 1 '` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 1 2Is' / ]) Registrar of Vital Statistics (.,&) j J (signature) i! District Number 5 6o 1 Place 6 hv.. sc3, `irs t1/4y k!` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ill u Date of Disposition DE( 1 call Place of Disposition ,� Ko C.Milr.ddiws 2 (address) ill ill i1r (section) (lot number). (grave number) p Name of Sexton or Person in C arge of Premises e it(13- )14 e- S etiellfi z (please print) 44 Signature Title CRer'1l}i00. (over) DOH-1555 (02/2004)