Fuller, Cheryl NEW YORK STATE DEPARTMENT OF HEALTH R ��o
Vital Records Section Burial - Transit Permit
Name First C ` Middle Last FL �Y, Sex
Date of Death J ` Age If Veteran of U.S.Armed Forces,
12 (I 5 ) ( -1 (.q War or Dates
ce of Death Hospital, institution or G�,h S F,L t 1 S 1v,S?,
Z City Town or Village C".LY)S rcz,l f Street Address
anner of DeathhlNaturat Cause ❑Accident El Homicide ❑Suicide Q Undetermined ❑Pending
ILI Circumstances Investigation
W Medical Certifier Name Title M
CI JC S Nov
Address l Y 0 't-. " C QX\S f a- '4 kJ I ? O
Death Certificate Filed n R ^ District Number n� Register Ny.
a Town or Village �n S f Y` ) 1�- `-i OD
I Burial Date (( Cemetery or Crematory
❑Entombment 1 Z 1 hq 1 i FI YU V Ica) ae_fr
Address U
,ltr Cremation oa-Y.A ( �t aci -e-e:nS b ./Y- I N'`( 12 Fro y
Date Place Removed J
Z ri Removal and/or Held
and/or Address
Hold
V▪I
0 Date Point of
tu Transportation Shipment
by Common Destination
Carrier
a[ Disinterment Date Cemetery Address
Reintermen# Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1A ft t,f l af d.b. Ex-1 Ker Fyne rct o Oo ry-lft._ Oil t o(
Address
`t Lai-ajeiie b rQe+ , C ec nsl-xoc.j, Ne UJ `1oc-1L 12 Ysot
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
Ct. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 2-1 1 9 Jar iegistrar of Vital Statistics L6 W
(signatur
District Number 560 I Place G CMS \\S ^t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k.
iik Date of Disposition IL I tjfil Place of Disposition emi.V .., Lc.
2 (address)
Lii
W.
CC (section) /(!ot num ) (grave number)
0 Name of Sexton or Person in Charge of Pre ' es . !-
U �� (, -se nf) 1'I'
(/.(�I Title !
Signature '�� "
g.
(over)
DOH-1555 (02/2004)