Fuller, Dianne IC
NEW YORK STATE DEPARTMENT OF HEALTH * tt 7!/t
Vital Records Section Burial - Transit Permit
Name Fir i ) Middle ..-J�.^ 1Ta4st Sex _,
Date of Death Age If Veteran of U.S. Armed Forces,
l 1 .I ( 17 6/ _ War or Dates
w- Place of Death Hospital, Institution or
own or Village f-�1-4 S Street Address 2(6 C,ki I^ y'c4•.42_,
. ner of Death❑Natural Cage � ccident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI iu, 5 tL =`S�1ot AA ,,,./, v ,'4c t MA
Address
S r_-4, . J4' ) air '� . ,r"'°�'�' `X,,, 1U`7De.th Certificate Filed U / District Number U gister Number
WI.; ttir own or Village krn--4-„ s 't Sot
■Burial Date (/ / Cemetery or Cremator _ /'
❑Entombment /.1 c /a c7 ,n A V C C +ir.M� -,o ram/"
Address �, v
[Cremation _ ( .�GeAS ,>r fU�c..) /0
Date Place Removed
Z Removal and/or Held
9,❑and/or
F- Address
t
Hold
0 Date Point of
12 Q Transportation Shipment
t
Q by Common Destination
iig Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to - Registration Number
Name of Funeral H �<> .)rr 7I—// ,/,(___,_ ' - —rig
liTAddress C,J
7 t`^`e....0.. Ave e—�,. u..-L /J7 / ) `o)._--
Name of Funeral Firm Making Disposition or to Whom i
114 Remains are Shipped, If Other than Above
Address
IX
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` Permission is hereby granted to dispose of the human remains-4 cri ed ab a as indicated.
F. -1of i
Date issued Registrar Vital Statistics �'`-�
(signature)
District Number 45-0/ Place r-t,4-t ,AP r ;;
• I7
I y
certif that the remains of the decedent identified above were dis.1sed of Fh accordance with this permit on:
n�/
t Date of Disposition 9/2b I r? Place of Disposition f� l�r�^1foru._
a (address)
LEI
411
CC (section) A(lot number) r (grave number)
0
p Name of Sexton or Person in Charge of Premises t'4)'t )1mti
Z ,, (pie se print)r
Signature t1 �Jitsp Title 6 (E M194
(over)
DOH-1555 (02/2004)