Loading...
Kellogg, Grace *I 4r Liu NEW YORK STATE DEPARTMENT OF HEALTH x ' Vital Records Section Burial - Transit Permit Name FirstMiddle Ask Sex &race- Date of Death Age If Veteran of U.S. Armed Forces, a i-- - rf (70 War or Dates N a 1-- Place of Death Hospital, Institution or Z City, Town or Village g iiiah WPW Street Address / OAL--4- AU ye.- 116,4 e tu riManner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier / Nape Title is -%,3r/es illJi's pi, r1-6 Address q l/ l PA rIC 3 fi ve:7— 'f r'2 p b e-A 4;43 ii Ny, I oq 3 a Death Certificate Filed District Number Register Numbe City, Town or Village Cl,x4311--A rao.'►+3 j 5 3 0Burial ' Date Cpt etery or Crematory [Entombment Addre silgy l�// e4; er /g y" ss l',V 1' emation Je-0--4-s 6 t -1 ix-. , Date Place"Removed 9Z❑Removal and/or Held and/or Address t" Hold 0 Date Point of ft Trans 0 Transportation Shipment G by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home £C'dwA,-L 1, . /(1-//ri, €na ( ,e10:6 Address 5 c4r-fi, AA l-e- N : /,z�"26 iiiig Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address CC fa Permission is hereby granted to dispose of the human - ins • -scribed above as indicated. Date Issued ©l �a I i 1 Registrar of Vital Statistics or" c� � a; ,�_ LLJJ��(signature) District Number l Place adeieyAkrztryi I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ILI Date of Disposition i'i4p/(1 701i Place of Disposition 42,u Oc,) Cre/`f1 dr,u41/4 (address) fa ir (section) (lot number) (grave number) ' � Name of Sexton or Person in Char of.Premises il r r,s} ht( venota' 2 (please print) 0.Ui Signature Title a t it1 orL. (over) DOH-1555 (02/2004)