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Howard, Camille _.. , .Jury I ATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Oil Name First Middle Last Sex C1 t L LE }�\I rlt\i.C, OCA)A �y 4-FmALE, Date of Death Age If Veteran of U.S. Arr ed Forces, EllS F,A. k(v ) A 0 l l ,515 War or Dates /A 14. Place of Death' Hospital, Institution r City, Town er Village �7(,Et�l S ZL $. Street Address (�-L aS LI.,s -\ s?VIA 1.-- Manner of Death�jj"Natural Cause Accident Homicide Suicide Undetermined Pending t + Circumstances Investigation ta Medical Certifier Name Title ' ' q Address c\3 p miiii Death Certificate Filed District Number Register Number City, Timm'or Village G Le N.s i.L S ,57p cy 7 7 []Burial Date ` rematory Entombment 1 g) a O k k I ry 6 X t e LJ � �m f 22 t.t t./vc., Address '' ( >_ Cremation U {kI�ER � o E6� (l�SjA o�� "t o Date Place emed Z ri Removal and/or Held and/or Address tt Hold ( 0 Date Point of Q Transportation Shipment iC by Common Destination Carrier El Disinterment Date Cemetery Address • glii! [�Renterment Date Cemetery Address ilM Permit Issued to Registration Number Oliii Name of Funeral Home?- .t(y3F,Kfi! E) k(4C1 oft 9' Address S� CI b t ri A j LAKE G©ic-€ 3 rl.rItiz..1Z ;� Name of Funeral Firm Making Disposition orAo Whom Remains are Shipped, If Other than Above M Address Ill Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued a )7/)) Registrar of Vital Statistics l.N.) CAA/in-1' -A-^ (signature) District Number 5-6,0 f Place acett,,& -LL s, 0 az fzti I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: O. CIA. Date of Disposition t 4Ktioij Place of Disposition 1nii) 40fi'-_ (address) (section) �� (lot numb -- � (grave number) Name of Sexton or P rson in Charg of Premises r.s that s (please print) i Signature Title CO E i O-- (over) 1-1555 (02/2004)