Hunt, Anne NEW YORK STATE DEPARTMENT OF HEALTH a. G
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex F
H n Yle. . u n+
€: Date of Death Age If Veteran of U.S. Armed Forces,
8/2 ZO if q6 War or Dates Aid,/ Hospital, Institution r
#�- Place of Death p , �jr i+ ('
ii City, Town or Village r M,1 t�- Street Address rl€Q5a r1+ Ua(ky -Lot"r WI(i_ I
Manner of Death.Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending .
W. Circumstances Investigation
Ili Medical Certifier Name -: Title a
Address
II3i-1 5+ e..t-zq C(eenividtn, A)1 it 3`!
Death Certificate Filed District Number 5. ,�--U Register Number
til City, Town or Villageiiii
❑Burial Date Cemetery.or Crematory
❑Entombment /�/��' ?l 1L '%J
Addre s �/ {� I 1 L ;
[Cremation iuAC6r F-C1 QL1 b151fU I'‘ U7 IZE3 O Li
Date Place Renhoved
❑Removal and/or Held
0 and/or Address
I:: Hold
0 Date Point of
Transportation Shipment
2 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Re istration Number
Name of Funeral Home '_ropy\-1ry�'1C m 0-1# Vuonerctl ‘10,n-,-e Oo I L! I
!i:lil,ii Addre s
c pines+ CI64-er-}wort, Ali 12817
gli Name of Funeral Firml Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
C
Lu
fX
Permission is hereby granted to dispose of the human re 4 describe abov indicated.
Date Issued 8/ 91 i Registrar of Vital Statisti•. �,
(signature)
District Number 57 J j Place
l bGt-)YI 6-441-7- (Q
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
P
fU• Date of Disposition '<- n%- t Place of Disposition fi ‘..tU1.0..! Cr"*41 ori--
2 (address)
ua
IC (section) `` (lot number) (grave number)
Name of Sexton or Pers n in Charge Premises r\Lif1 Si•-ate
I(please print)
• Signature Title t'n-7446a
(over)
DOH-1555 (02/2004)