Goodsell, Joan NEW YORK STATE DEPARTMENT OF HEALTH 7T
Vital Records Section Burial - Transit Permit
Name First Middle u Last I Sex
> Date of Death / Age 1 If Veteran of U.S. Armed Forces,
:: ~ / -7 Z 1 War or Dates Ai q-
Place th • " ton or • 7
City Town Village 0ucen1_s(, iilitt- Street Address 3c1 CL6-j7e,-IT S I ;
Manner of Deat Natural Cause fl Acc-ent fl Homicide ❑Suicide 7Undetermined B Pending
Circumstances Investigation
tu Medical Certifier Name f) Title
CI 1161",1 4-- 0 4 0/1..) PI 6
Address -
VIVI/3 GU&IA&e--,,J-c 6 uyz_. Ai(-/-
Dea • -•1 icate Filed Dis u e ister Number
City, ow '► Village 0 v "e ,J S a Y' � ( j
❑Burial 1 Date yy Cemetery o CrematorF
:::::::r_, I 3 /S4/?0 Entombment r nl el- /b�
Address Ai7
1�Cremation Q vy3-i ��--- i 2j C U L-.�.�..'Q 01- J
"' I Date Place Removed
❑Removal 4 and/or Held
and/or Address
tri
Hold
0 'E Date Point of
Transportation I Shipment
is by Common Destination
Carrier
Disinterment 1 Date Cemetery Address
❑Reinterment Date 1 Cemetery Address
Permit Issued to t�-} '. Registration Number
Name of Funeral Home l .�t_TC:.- ;fit ZA\ HO c1 . C,1 1 .;C`
Address `:' ,-.: -,,.
\L LC=.. 1l e--�t` �- C.. '- is C_`.t� is 1 ' KsA 1.--2, c,k
;> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
Ill
Permission is hereb granted to dispose of the human "ns des e b as indicated.
Date Issue Registrar of Vital Statistics
� � � (signa�ura) '
District Number e4-�r e")--) Place ) �111....r.N
I certify that the remains of the decedent identified above were disposed of in accordanc with is permit on:
.14
Z I
tit Date of Disposition yiyil +�Place of Disposition Pikla mi/ e-/2 GyvI(address)
ILI
to
r (section) ` (lot n mber) (grave number)
ta �J tti I.C_vl G.,t�tiC G Cht
Name of Sexton or P an in arge of Premises 6
(pleaseprint)
44
Signature - Title G/'e-r✓ et.
(over)
DOH-1555 (02/2004)