Willard, Joan NEW YORK STATE DEPARTMENT OF HEALTH" k44 152C.
Vital Records Section Burial - Transit Permit
Name First i Last S
0 a ) r :_7.)
'' Date of Death Age if Veteran of U.S.Armed Forc
1/ I to /6 P-S War or Dates
i ` Pttaath HospitalO nnstitutio r
r4 C , ToviOr Village Q J e hi S Q Street Address —BAIT-ILJ
mi Manner of DeattRNatural Cause Q Acc. ant Q Homicide ❑Suicide ri Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title l
ICCs��t 5219 AJ c cr" /1, �(J
Address
.. ) /11,P" C;--p ^Jib,..) (j u tx-..k.13_e
Dear Filed District Number Register Nu ber
C Town Village 0 ,�nuy7 S� 1 ( C,
El Burial Date Cemetery or remato
❑Entombment // /7 / 6 i,..�s u
[3�
Address n ^ j
(F.Cremation 0 0*"710-`- r`.`t G U .�3 � /II
Date Place Removed '
r a Removal and/or Held
and/or
Address
Hold
i
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 14Gynat8 1�, Exke- v ccc1 {{vim_ rs,1J 3O
:- Address
II La c-He- SA. , &ueeensbu,ry , tJt„.-; NiorlL 12' '0t--�
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:ati
ITEI
Permission is hereby granted to dispose of the human remains described above as indicated.
_ Date Issued , k I .I U` (�, Registrar of Vital Statistics --R4-1 -AkAc, .Q .�
1 (signature)
District Number 0517 Place Q U c e S J U/
I certify that the remains of the decedent identified above were posed of in accordance with this permit on:
ial R J .Date of Disposition �*- Place of Disposition ru- r �, a t 3 hv•N
hii (address)
111 i ( I lb
E°.1 (section) (tot number
r�i (grave number)
i". Name of Sexton or Person in Charge of Premises CI r tJ( bt 3 t't,tt
Riplease print)
Signature Cl % Title !( AAPATZit
(over)
DOH-1555 (02/2004)