Tremaine, May c 4
NEW YORK STATE DEPARTMENT OF HEALTH. 4 b 35"Vital Records Section
Burial - Transit Permit
Name First Middle Last ___ Sex
,. Date of Death t 1 Age I If Veteran of U.S.Armed Forces,
C , \OZ+ ?_ LC) I I War or Dates N 4-
P .ce of Death � 1 zspitaZ?Institution or
3
'. 4111011Town or Village cx z �Q\ .S Street Address (4e:+\S O.\1S p i 1 \
It Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Q Undetermined fl Pending
I Circumstances Investigation
0
L Medical Certifier Name __ Title „
I rv\t7=1-Y\.i kv,(P�/ r'o'neY" 1
Address �^
Z CAA), \aYVt A'N1-e- i C--s UxNs YG\\S, js. Mgt) )
Death Certificate Filed I District Number Res er
`it own or Village L-5-tens Fix\1S(— 1 %Di
Burial E Date \ } Cemetery or Crematory
1 O`-t 2-0`� ! t Yl L V i �J C`-CvM A A-or y
;_ ❑Entombment Address
--:,,:i-:[Cremation Coa\\LY cLDIkCC C \YeevS�ur� i N' 12o'I
Date Place Removed
t —Removal and/or Held
—and/or Address
Hold
0 1 Date Point of
:Q Transportation Shipment
by Common Destination
Carrier 1 _
`>'❑Disinterment I Date Cemeter y Address
C Reinterment Date I Cemetery Address
: Permit Issued to y-� . I Registration Number
Name of Funeral Home L '�L ;1 LZ, �\ t-\D“.1{-- C ::t 1 I C
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ir
111
Permission is hereby granted to dispose or the huma remains d cribed above as indicat d.
Date Issued Og( !a(n 1 Registrar of Vital Statistics �-�?E'�� a ' -
(signs
District Number 5600 i Place C D
I certify that the remains of the decedent identified above were disposed of I accord ce with� this permit on:
iti Date of Disposition q`dlf(L6 Place of Disposition rnl i LN"` d rt"~-
(address)
l
tot
(section) (Jot number (grave number)
cName of Sexton or Person in Charge of Premises LILL^ B"Nit
/�,( /) (please print) �,r�i
Signature et /S/ Title �a 0PR —
(over)
-
DOH-1555 (02/2004)