Swann, Sally NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial ® Transit Permit
A Name First Middle . Last S Sex
S,1iy , 5��2. ��avnn F
�= Date of Death I Age I If Veteran of U.S.Armed Forces,
.;:: N 1)
` �` 1 b I 2 -'1 � I War or Dates
Place of Death r- ' Hospital, Institution or
Town or Village GA en s Fa 11 S Street Address &i ty's Fa 1)S cSe;fa
114
anner of Death r Natural Cause 0 Accident fl Homicide 0 Suicide ri Undetermined ri Pending
Circumstances Investigation
IAA Medical Certifier Name Title
Pt N iC e\ ,1; 1e5 A � ,A5 Ph,j5, c ,0..n
Address
IDO Pay IL S)-- - �'tt) 0S FallSj !VI I 2-c'O1
>, Death Certificate Filed District Number Register Number
,,.:1.46,00Town or Village G1 enLS r—a 1'S 5G 0 I 5 .
[]Burial ' Date Cemetery or Crematory(Liz U',
[]Entombment I o 1 14 12.el‘o p; a w (' 4nc�c}vy'r
Address
IZICremation C ,,aur (Lc d C.>Lyee..r,sloo r Av.4 i 2 goy
Date I Place Removed
Removal ; and/or Held
P and/or Address
It Hold
co
Date Point of
cnIL r Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
_'` Reinterment Date I Cemetery Address
I
Permit Issued to I Registration Number
Name of Funeral Home tC.- >�i-\e_i-OL1 \1 S \t- C=11 ,,
Address
11 LeSa.N-1 C. - L - Lt~c=i�c\— . - 1 N 17-` Cat
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
III
Permission is hereby granted to dispose of the human remains escribed above as I icate .
Date Issued 1 o i 4(?c1Lp Registrar of Vital Statistics
(signature
District Number lj(�7 Place /-2 -�' ' `7
d
I certify that the remains of the decedent identified above were disposed of in accordan with this permit on:
Pa Date of Disposition /0118 jlt Place of Disposition mUwtj Ctt44X+4--
(address,
Ili
DI
IM (section) (lot numb") (grave number)
CI Name of Sexton or Person in Charg of Premises 14144 r
2 (please print)
to Signature ei Title t /914111
(over)
DOH-1555 (02/2004)