Straut, Tina ' it 5zg
NEW YORK STATE DEPARTMENT OF HEALTH -
Vital Records Section , Burial - Transit Permit
<' Name First Middle Last Sex
EM Tr o.. Mar;C. S-roov V
> > Date of Death i Age I If Veteran of U.S. Armed Forces.
>> I a5 )ao0
- o1 I 51 j War or Dates N l'A
:iio Place of Death i Hospital, Institution or
own or Village Glens Fa\\s- I Street Address Gte-r s Fc\\S 40SP1a-O'1
Manner of Death i�� Natural Cause El Accident Q Homicide 0 Suicide ❑Undetermined ri Pending
la Circumstances Investigation
119 Medical Certifier Name Title
0 TaArC i Gc.;cAlri -G robbs N\ TJ
Address
I oZ Parma S+rcAQA-- Glo.rus FD.\\s, N
1 z. v 1
Death Certificate Filed i District Number Re ister Number
i c Yown or Village �Ic \ '�a\\ S bG,o I �-.1g
IDate I Cemetery or Crematory
E Burial O1 la1 J ao\k yn \I P', c. rev..) C�maro
Address -
':: Cremation) ( v0.Vhe - Road , Qveersburi i N'( \ZOO y
i Date Place Removed
g❑Removal I and/or Held
IT and/or I Address
Hold
0 ` Date _ F Point of
fpi E Transportation,j Shipment
Es by Common Destination - - •
Carrier
=: Disinterment Date ! Cemetery Address
Reinterment f Date i Cemetery Address
i f-
. —
Permit Issued to I Registration Number
Name of Funeral Home_ l?L -;,- -`. _ 01130
Address / r
yr` l_ -�.CT, '`I
�-��= 1• ilv; fr ,
11 Name of Funeral F Yrri Making Disposition or to Whom J I
.i2; Remains are Shipped. If Other than Above `
Address
Permission is hereby granted to dispose of the huma remains described above as incl. ated
"g Date Issued Registrar of Vital Statistics in i• ./ , ,f, miL
{ (si.n. ure)
=' District Number 5"l,0 / Place ,r_A/ /�IJ
, `---77
:::„.„,,,
• . ./ .
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I certify that the remains of the decedent identified above were disposed of in accordant vith this permit on:
Date of Disposition -7 1 z8 fit Place of Disposition ?4,-/ `.w..airm....
2 (address)
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U)
lX (section) (lot number) ( (grave number) -
0 Name of Sexton or Person-in Charge of Premises ast n0211
i (please print)
W Signature L� Title CItVIiIM
t
- (over)
DOH-1 555 (9/98)