VanYuren, Catherine /i 7zy
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial m Transit Permit
Name First Middle Last ‘I ,,ii \ Sex r
C G .� 4 M vay►\tf.PY-eh r_
>= Date of Death Age I If Veteran of U.S. Armed Force ,
€> lot 03 i ao‘to I qj I War or Dates
Place of Death Hospital, Institution or
th City, i own r Village �e2rS\vey I Street Address
r Manner of Death ILM Natural Cause 0 Accident 0 Homicide 0 Suicide Ei Undetermined 0 Pending
I Circumstances Investigation
Lid
Medical Certifier Name Title
IP Gera\d 0)02�S M
Address
S 1(o,n c PoNr\ -ef/ -� S Fa \s, \1 12'0 I
Death Certificate Filed I -ct her Reggter Number
City d o . •rVillage Q.�eef,31o�(- I � ' ) . C)
_<>❑Burial
Date I Cemetery or Crematory
Ip101.# iatA P% \, evJ aity-r.a vi
❑Entombment Address
iCremation no Thy '12-00.6 Pv,3`p„ryy y i ZBUL/
Date Place Removb`d
Z n Removal and/or Held
and/or j Address
t/-1
Hold
0 Date Point of
Transportation Shipment
ES by Common Destination
Carrier
❑Disinterment I Date Cemetery Address
E Reinterment Date 1 Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home '1ex i-x�;Zx\ \c \&_ C'=11 ?L
Address cc
Name of Funeral Firm Making Disposition or to Whom
li Remains are Shipped, If Other than Above
2 Address
M
w
`: Permission is hereby granted to dispose of the human re ains described abov9 as indicated.
Date Issue ' = Registrar of Vital Statistics C.� Q C1 JLA_ _
10--( (- \ o t(. (signature)
District Numbe ", _r Place-� CD_
I certify that the remains of the decedent identified above were disposed of in accordan,a with t is permit on:
ill Date of Disposition lb/Sig, Place of Disposition ftu UuJ c,aril t.-,
2 (address)
l #
0
t (section) AI (lot number) (grave number)
O.
i k Name of Sexton or Person in Char e of Premises / � 1 one
( lease print
Signature ir Title C1 .-
(over)
DOH-1555 (02/2004)