Graves, Louise NEW YORK STATE DEPARTMENT OF HEALTH f 1 -WO
Vital Records Section Burial - Transit rermit
Name First Middle Last Sex
1. LOo\ (Z-o S.Q V\.r4 s F
Date of Death �' 0� Age ct If Veteran of U.S. Armed Forces,
{201� l \ War or Dates
e of Death Hospital, Institutions Fsor/'� f L i_
Town or Village Glen tt Street Address la\Q InS (' S 1� _ A)t 1
anner of Death CZ Natural Cause � Accident D Homicide D Suicide 1-1 Undetermined ❑ Pending
, Circumstances Investigation
Medical Certifier Name \C �\ i\ ��S Title
: C�
Address lL\ `b QaC.. , ,.,k,.., cpke,,,, \\,. \lta3
_ ' Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date p I t I Z�1 Cemete or ere`m�atory
Entombment Address //�� p�o`-'Cremation '2 i Q..cc ec,c) Qev1S N't 12 I
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
° ❑Transportation Shipment
by Common Destination
' Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to M t� _ Registration Number
Name of Funeral Home i I a l �nr�e� t L.i✓lfjc -)c►/M1Q O 1 O I-i
Address %Z— ( Ff"- GA-JOV‘d )3j a K1 Z�
Name of Funeral Firm Making Disposition or to Whom
., Remains are Shipped, If Other than Above
' Address
ri:
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t C / (C? l G7 Registrar of Vital Statistics (A) C.lvki�� (signatur
District Number , 6 0/ Place 6 Cs Fa Ja 1 13 ,�y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /0110 1 Place of Disposition
n..v., er+,•G,fa;+--/
(address)
(section) /At number) �-, } (grave number)
1...,
. Name of Sexton or Person in Charge of Pre ises d r'i -Scv '(pl ase print)
Signature 6 Title (Fit/hii9/L
(over)
DOH-1555 (02/2004)