Harwood, Anna I
v. 4
t7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit rmit
Vital Records Section
Name First 11 Middle i Last Sex
Pima Mom'c H1,AJek
Date of Death Age If Veteran of U.S. Armed Forces,
5/ -7/ 2 0/7 '7 7 War or Dates
f-=. Place of Death Hospital, Institution or
City, own r Village U 1 eet A 9 Igo/ d Ci�-e
LIJp Manner of Death qj Natural Cause 0 Accident 0 Homicide El Suicide �Undetermined Pending
ttl Circumstances Investigation
W Medical Certifier Name Title
0 i'C / iC - ( u_thr IVO
Address
/4,c ga-ork- Sr�P--e.-i �'r6/1 r fah /V V 72 6-a/
Death Certificate Filed r
D of time LL4
r Re i t?r Number
City, ow Village Ce1/ JbJ (
�S9S��
❑Burial Date
51�3v/1 Cem tery or Crematory
4--e V Cie 44al-4nl
0 Entombment Address
gCremation OL,ale-,c 9t.Gl. �L(aAr Jay NY /2Jv,V
Date Place Remdved
Z Removal and/or Held
0❑and/or
Address
Hold
CO' Date Point of
Q Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
_ Permit Issued to Registration Number
Name of Funeral Home &.\4-jCC r L i- e c r± \ -O t`Cl t- C�11 3 0
Address kt LG.. e- - - ' ,(: r vim .%r i i cz c i
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
re
i:Ll
a" Permission is herebyl granted to dispose of the human r^ in described a as indicated.
Date Issued 01 l r3 Registrar of Vital Statistics )
(signature)
District Number cLD --) Place___1 a d ..r l ) ale
i-:
I certify that the remains of the decedent identified above were disposed of in accord., this permit on:
11,1 Date of Disposition L I, in Place of Disposition ?Ingo-(address) f n��4orice.
Lis
Cl)
1e (section) J/(lot number) �- (grave number)
GName of Sexton or Person in Charge of Pr mises L Arts -er Svtill tt
(please print)
Signature Title OZ 6 0)fi.
(over)
DOH-1555 (02/2004)