Tyrell, Jane Jun. Li. LUI) I ;L7rIVI r iuo. ,,,,, 1 r 1
NEW YORK STATE DEPARTMENT OF HEALTH (eZ
Vital Records Section Burial - Transit Permit
`it Name First _.. Middle Last Sex
g, Jane E. Lyrell Female
.ia Date oIDeath I Ago if Veteran of U.S, Armed Forces,
;`' V,War or Oates
1::: Place of Death Hospital, Institution orCity,Town or Village
Cxanvi 11e Street Address Indian River Nursing Home
Manner of Death u Natural Cause ❑Accident 0 Homicide fJ Suicide Undetermined Pending
Circumstances Investigation
_
Medical CettCertifierName Title
- Lros Girton _ M.)--_______.
is
;� Tess
t5- Pout_ st_ f--- ' , .
A Death Certificate Filed District' um er Register umber
iaL _
City, Town or Village Grartvil?a 5
{'°;DBurial Date Cemetery orCrematory
V 06/27/2016 Pine View Cremabory
Enromtxnent
1,' I Address
<tY®Cremation ' 21 Quaker Rd,,-,lens Palle, Ny 12Rn 1
a' Date Place Removed
L.J Removal and/or Held
and/or Address_
Hold
Data Point of
0Transportation Shipment
by Common Destination
Carrier l
414 Li Disinterment
Date Cemetery Address
A tDate Cemetery Address
u Reinterment
""Permit Issued to Registration Number
Name of Funeral Home Alexadf=.r-Ha ker Funeral Home 00037
c f Address
>" 3809 Main St. , Warr
Name of Funeral Firm Makin Dis ositionorto q NY 12 S t}s-- —i R Whom
Remains are Shipped, If Other than Above
Address
Permission i.s hereby granted to dispose of the human remains • s . : • ' indicated.
►r. i ►�
Date Issued 0 6/27/16 Registrar of Vital Statistics �), k If dal41
_
ei
District Number 37 L V Place 1 ((u cfeOf- c d(e..ecru )
_ f -
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
I
Date of Disposition•_ (r�Z4l(;o Place of Disposition -gneu�..J (! iN-1 ry
(address)
(section) (foi number) (grave number)
Name of Sexton or Person in Charge of Premises N r.s St n'''0'
please Rani)
Signature Title _ _ 01" 9K 1 ,4
(over)
DOH-1555 (02/2004)