Hill, Suzan i
€JEV. aYORK STATE DEPARTMENT OF HEALTH 41 13
'Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
SUZAP L. IN/ P
Date of Death Age If Veteran of U.S. Armed Forces,
4/�'/V0f 7 �`' War or Dates
Place of eatt( Hospital, Institution or
5 City, Town or Village 6 �1•'t� & -
y g ,����.,� r Jl� Street Address
C—
a Manner of Death�Natural Cause Accident El Homicide 0 Suicide 0 Undetermined n Pending
at Circumstances Investigation
W Medical Certifier Name Title
a ati,) o 'ou[ep b 9 )1417
Address
/X , 5T G/e,... 44,5 /
s Death Certificate Filed / District Number /�� Registe Number
gil City, Town or Village nifipke.ySTS---R.
Eli ❑Burial Date Cemetery or Crematory T
❑Entombment c�c� � �� / ik)C .iif'L� cF-P /4 /%-
Address
remation 2L1ee btl/e P
Date Place Rdmoved
Removal and/or Held
and/or
E, Address
Hold
C
0 Date Point of
) Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
i!PEl Reinterment Date Cemetery Address
DO Permit Issued to Registration Number
Name of Funeral Home 1 '00S in are,.. 1—UPPPAL ROA-T�. OO g-
NI1 Address
5Ae1C, rn11,0 Av-e Cox L , k,F4
Name of Funeral Firm laking Disposition or to Whom '
Remains are Shipped, If Other than Above
• Address
la
tr
Permission is hereby granted to dispose of the hum1r ins described ab ve s indicated.
Date Issued _ /V c/o/7 Registrar of Vital Statisti
ipl ( gnature) J
District Number �5 cg Place /A Aae>' J3
I certify that the remains of the decedent identified above wer0 disposed of in accordance with this permit on:
tLI• Date of Dispositionlilt,jn Place of Disposition 'GntVI,;,.r Con etof,,,--
(address)
iti
lM (section) /� (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ` ')ns\,Li .Sttflntff
(pl ase print)
t t Signature 4 1 Title a'ft
(over)
DOH-1555 (02/2004)