Harrison, Barbara NEW YORK STATE DEPARTMENT OF HEALT ; ., -" sz
Vital Records Section Burial - Transit Permit
is Name First fiddle Last Sexc
Date of Death 0 i 7 17 Age If Veteran of U.S. ed Forces,
War or Dates
Place of Deal 1 n n Hospital, Institute• .•r
I City, Town& paq� r L Street Address =•, /a&p Gr f t
a Manner of Deathatural Cause ❑Ac 0 ent 0 Homicide 0 Suicide Undetermined �Perfding
iii
Circumstances Investigation
in Medical Certifier Nam Title
0 tY_ille_ \'"i .,,,, n kPA -C.,
3 A ress
lid Death ificate F• d District fyiirr gister Number
> C. ow or Villageilg '�f
urial Da2 ' '
CI 7 C et�ry or�r¢mato
1 3E1'tLtY o ent ss
i
iiiiiiiii emation
Date P e Remov
❑Removal 4e.J '
a /or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
''j El Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
ii,>. Permit Issued to �n � ��.kJAA Registration N mber
s Name of Funeral Home f 1 15 rU2k 1-t.4 ilQI24 4 4_, O/D 7 ct
`'>: Address -�� ( �, , O�. t .)l • iqoZ o
<<: Name of Funeral Firm MakingDispose n br to Whom _A�-L-C�
Remains are Shipped, If Other than Above
Address •
It Permission is hereby granted to dispose of the human r described a e as • dicated.
•<3 Date Issued 1/)i o 117 Registrar of Vital Statistics ►� A L
igna re)
iiig District Number 47013, Place /hi r ,
I certify that the remains of the decedent identified above were dispo.- of in accordance with this permit on:
Date of Disposition ►I)/1 Ili Place of Disposition t r tiu✓ � i...
(address)
tit
(section) /'�/ (lot number) (grave number)
1 Name of Sexton or Person in Charge of Premissf(ro .�."1(
(pllse prin�
7.7 Signature irA
Title freiti rift_
(over)
DOH-1555 (02/2004)