White, Betty Ann It
NEW YORK STATE DEPARTMENT OF HEALT.-1 ' � ‘
Vital Records Section Burial - Transit Permit
Name Firer - /9:4747Middle ,) t n / Ste, //
Date of DDE th If Veteran of U.S. Armed Forces,
6I v O` Age/7 "I
War or Dates
-- a of Death r -j Hospital, Institution /' `
eit , Town or Village (ims- u/,i Street Address W� J-7�{ � 0` .
anner of Death 1 Natural Cause Ei Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
Circumstances Investigation
la Medical Certifier Ci ame `h R.. \It +i, Title
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Certificate Filedr
District Number Re ister Number
/th
Town or Village �� _ �L�' � g
❑Burial Date-, j j r'`� ry or Cr�em�atorry /--
❑Entombment V ( ®< [tl ?C ���� / �.sr1D' yyj
Address
remation ( C( 4;a7 A cG(C-e'er'!--rk-- ,,-l// lJ��"y
Date Place Removed
Z❑Removal and/or Held
and/or Address
ti": Hold
in
O Date Point of
eci n Transportation Shipment
Ei by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to , /- Registration Number
Name of Funeral Homo' j'� ----&T /a- ,,kie 0-- e%�l(�t 7,7/7.,,7,7,,li f� 7?e", G`-/ril
Address
,./7 7.2.7A 7 _
Name of Funeral Firm Makin Disposition or to Whom
9 p
Remains are Shipped, If Other than Above
• Address
M.
LU
fl Permission is here y granted to dispose of the human remains descri ed abovee Indic e .
Date Issued - / Registrar of Vital Statistics �jj 4,
signature
District Number jot/ Place el ` C e ��,
.r—Mb , 7 /2-16/
I certify that the remains of the decedent ide tified above were dispos of in accordance with this permit on:
IL I• Date of Disposition 1-s-11 Place of Disposition laVv./ ( c+o'w_._
(address)
Uit
til
CC (section) 6 (lot nu r) (grave number)
Name of Sexton or Person Charge of remises 7',
t1) r s, t.,wit
(please print)
Signature l�'► (t
9 Title C -rtw"TOck,
(over)
DOH-1555 (02/2004)