Wolfgang, Susan it 610
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last ex
t t ae)._ 1
Ave( cootf f .nC\ +e ai.Q.,
Date of Death Age If Veteran of U.S. Armed Foes, J
iii O W I'3v 1 2.0 00 -,j War or Dates
`` Pi ce o Death Hospital, Institution or
Ul
it Town or Village 3 et cR..Sp c►ri Street Address a q-0006
Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
W.
Circumstances Investigation
at Medical Certifier Name ,A Title
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dress
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Ei Death Certificate Filed District Number l 501 Register Number/t
ity�Town or VillageSO- & Se r, a�S `��
>> Burial Date�t 1 J 'Cemetery or Crematory
>'' ['Entombment a 9 )O) 1 �f � 1 '[ ii\P 1✓►t t, of Lv1C30 r�l'
Address �J
`i®Cremation etas i,ziAi..j 1 Ny
Date Place Removed
Removal and/or Held
and/or Address
Hold
O Date ' Point of
tL Transportation❑ P Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
O
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home in e). 1&,�\y► ,0.1 0/0- _
ig, Address
R-2- gig:o-di -- bir�- F 4(1,064 d ,ki4 1_2. -
``' Name of Funeral Firm Makinti Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
t
Permission is erebJ'2LJJ
granted to dispose of the human rem d cr' ed a indicat
Date Issued S 3 J (Q sRegistrar of Vital Statistics
&tir (signature)
District NumberI Place ` ri
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t �
III Date of Disposition qj6 fj(, Place of Disposition 'ILL, ccy -a."'
La
(ad ess)
CC (section) d(lot number (grave number)
0 ,
ei Name of Sexton or Person in Charge of Premises A k- 3PI
(pl$ase print)
Signature Q Title MwrtTQ
(over)
DOH-1555 (02/2004)