Venon, Thelma NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
tit Name First Middle f1 Last 1 Sex
I he.i _ck 12510Y;ck Ne..eN OY1 F
Date of Death , Age I If Veteran of U.S. Armed Forces.
ag p(.q 1 101 201 l9 MI j War or Dates 141
' ' Place of Death i Hospital, Institution or
Town or Village G 1 er S FQ)IS 1 Street Address 3o VlenS i r j}ovi
.4isManner of Death N Natural Cause ❑Accident ElHomicide ❑Suicide t t Undetermined (-1 Pending
t Circumstances '—`Investigation
Medical Certifier Name Title
!rb 4v&N'
Address
1 iit1 2 -(-
Death Certificate Filed I I District Number / - 4 Registe N er
.► Town or Village ( nj r,� Fc,.\\-S 3v V I. p�y
Date I 1 Cemetery or Crematory
❑Burial Oo i3 12Qi( I i Ol e_ Vier 3 ma-i-orl
Address
Cremation G.�0.�.Y KcX.C1 ) (•�„eenSbo
I Date _ ; Place Removed
1❑Removal J and/or Held
-. and/Holdor Address
�"
0
4 Date t Point of
rii El Transportation, Shipment
a by Common Destination - - •
Carrier
El Disinterment Date Cemetery Address
El Reinterment iii Date Cemetery Address
<= Permit Issued to _ / S Registration Number
Name of Funeral Home 3 - '�--..; 3i; lfL:Y!- { 0//So
Address i if J� r,
--/ 6,--)062.-;-/J.c r or e4 Ay- : 1 2_,P-cl ii- . _
Name of Funeral F� Making Disposition or to Whom ,- t
Remains are Shipped, If Other than Above `�
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
p Date Issued 6 I i 3 i it Registrar of Vital Statistics W c u. W-A-AlAjt
ill (signature)
gii District Number 5 60 I Place 6 CAS 0,5, Lii
`.:- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1..4
ill Date of Disposition /Pff/t Place of Disposition ?ha, Gr or1.-
i (address)
111
U)
CC (section) /%�of number) (grave number)
0 Name of Sexton or Person-in Charge o Premises /�.rcf s
f"WAY
(please print)
Signature (,�L Title irkht. l_
- (over)
DOH-1555 (9/98)