VanAllen, Muguette NEW YORK STATE DEPARTMENT OF HEALTH TM 32.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
V(>U C l e G• ViAN ALl_ls N
Date of 0Death, Age If Veteran of U.S. Armed Forces,
1 O 2 01b $O War or Dates
} Place of Death Hospital, Institution or
W City, Town or Village Due G+�SU$ {Z.-`‘ Street Address T-4L: S-T A.N'� N 6
p Manner of Death®Natural Cause Accident 0 Homicide ❑Suicide ❑Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
P XOSC-i-t.►-i S 1..oe M:
Address
Wi -.c S1 ct..4 cs^ Sig C L.wl>AN lki<D OutiC N SW/et t1.1 kM49
Death Certificate Filed rnDistrict Number Register_Number
City, Town or Village cC,tJS bU Q-`1 s1i 5 1 5
❑Burial Date Cemetery or Crematory
O% 1 N.k 1 ao L 6 CI v c )c..•1 PA rs-ro�.ti
I❑Entombment Address
21CCremation QvPK..c R- toA'9 Qve;i: NS gL>�%,. t�-1, 1 at04
Y Date Place Removed
0 ❑Removal and/or Held
and/or Address
5 Hold
0 Date Point of
N0 Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Numper
1,4 Name of Funeral Home P GI-NSMO Q r L - L►oc- 14.0001 C OO44
M Address 4
t \
S4c R-v t AN �V 6- (:Q-1 N-t-l� .�s a2
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
Ct
41,:11Permission is hereby granted to dispose of the human remains described above as indicated.
kFti Date Issued ‘-1 I - gipt li Registrar of Vital Statistics -fit-i ,�
�4 (signature)
District Number S U 51 Place Q U�c._elS b1//lJ,t
HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /'
MI Date of Disposition 1/(3JIL Place of Disposition e 4l4,,.I (ri'v*c(ix'n..
E (address)
MI
U)
IX (section) // (lot number) (grave number)
pName of Sexton or Person in Charge f Premises 7Pr� S�„ itt
Z (p ase print)
U 61
Signature Title -
(over)
DOH-1555 (02/2004)