Harrison, Cecilia 1 # 35 )
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
N e First Middle Last ,Sex
Ce C-i i / rt. -k&rr , s ov Chl aJ
Date of Death Age If Veteran of 1med Forces,
1 )- as y -:�G I gl War or Dates U.S.�()
UV-
tPla�Ce of Death g 1 J Hospital, Institutionor DC f C
Cit Town or Village\ ^Ci� C.,)p ri 1 Street Address tra. ,4� r
a Kanner of Death Natural Cause Acciden 0 Homicide 0 Suicide �lndetermfned ni Pending
W Circumstances Investigation
W Medical Certifier Name Title
c Maria vtv' enZto. bi Q .
Address C
S a-rt 4 c . r 11153 +�
eath Certificate File - J DI �isrfr t Number Register Number
� 9
Cit Town or Village"(, .r( ,c et 1 - TJD
ti['Burial Date 1 J etery Crematory
[]Entombment ' 1 t"� ` i 1 ► e V i C re Malt f n
Address /�
Cremation C YL4&/15 (L I A) laQ p tf
Date J Place Removed
Z El Removal and/or Held
3 and/or Address
8 Hold
Q Date Point of
ti Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home C.k)e,r -L(fiord ( 1--oryK Inc- >!
Address u �u.Irk.V t <3t Lit' 141 tLM Ztry i t`i k J T e
.11 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
LEE;
Permission is hereby granted to dispose of the human remains desefi d flitove,aboinsfirated.
> Date Issued 11 )c1L'-I I 0 Registrar of Vital Statistics -1-j
ti
(signature)
District Number 4-5 0 ' Place1{' \
Li-i \ kick-3054 5Q r"" I certify that the remains of the decedent identified above were disposed of in'ccordance with this permit on:
>LI Date of Disposition li 1 r)(("1 Place of Disposition C,.�vr.. ( P,_.
(address)
Ili
fa
CC (section) (lot Amber? (grave number)
Name of Sexton or Person in Char a of Premises , hlu _ingt
2 , (please p t)
SW. ignature Title potpie_
(over)
DOH-1555 (02/2004)