Thibeault, Fay # S07
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
//? Name F EllEA, MiddlekAti IA Last Sex
Date of Death / Ag�j If Veteran of U.S. Armed Forces,
7/ ` O/(a b War or Dates
# Place of Death �� Hospital, Institution or
City,¢ow'Nr Village Street Address
Uil
L Manner of Death f Natural Cause El Accident El Homicide Ei Suicide ❑Undetermined El Pending
Circumstances Investigation
MLfjedical Certifier Name Titl
CI A%C-k.14 ICJ 141 t i •E VEK
ffi Address /
- /O a �'t"L c ` R� /e7on of tle6 C-,!f A)Y /2 'w -
0,1 Death Certificate Filed / �� District Number sr Register Number
City, own r Village 1-j' t0 3 i�
Date r� �jmetery or 9rematory /I
❑Burial /"o2�j O '14 P, (,'J E V l ►ki Ll:cm ic\-1-0 r
Address
Cremation
FDate Place Removed
I ❑Removal I and/or Held
L•• and/or Address
�" Hold
th
0 Date Point of
NQ Transportation 1 Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
s Permit Issued to � �� Registration Number
'> Name of Funeral Home b /r (0 "�6/�!J-/ /1 e,' 4 1 4-4 rn e_ O/ F2, I
Address /'r//t l�on _IA T 1- rl oil E 1�6 6 M' /V-7 - `2_g ,9 -
Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
Address
a
IX
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7/9-/6 Registrar of Vital Statisti s If I
gn ture)
District Number-- S: Place A---tel,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1 r
W Date of Disposition 7I 2 Mc Place of Disposition piai\c+✓ (rt,vatio,
—
2 (address)
LU
U
CC (section) ir (lot number) (grave number)
Name of Sexton or Person in Charge of PremisesCI ; Afs SP4P fr
(please print)
1U Signature Title camtvo
DOH-1555 (10/89) p. 1 of 2 VS-61