Honbouk, Audrey 2 tq
NEW YORK STATE DEPARTMENT OF HEALTH . •.*..
Vital Records Section Burial - Transit Piermit
Name First Middle Last
Er ek-/bin____ 0 iol7Ai< /Z COT- ___ Et-r
Sex
Date of D Age 1 If Veteran of U.S. Armed For es,
�l ( i P 8' j War or Dates ,Jm
ZPlace • II-ath I Hospital, Institution 99 1 / Aivi,f,
Ci , Town .r Village 4 GG- _ Street Address L13 �?�G
p Manner of DeathE ❑ ❑Undetermined (Pen ing
RNaturaldauseAccident Homicide Suicide 9_ _ _ _ Circumstances Investigation
,jj Medical Certifier Name Title
G
Address — —. — — --
Deat ' ate Filed District Number 5 s- , ' Register Number
Ci Tow Village (� ) V I
❑Burial Date I Cemetery Cremator
ScaEntombment— // ��
Address }} L
emation ur-x 1ti /2 ( v66`-�: r L1�J l "
Date / i Place Removed / r
O❑Removal L and/or Held
2 and/or Address
l Hold
0 Date Point of
N0 Transportation Shipment
G by Common Destination
Carrier
Ej
Disinterment Date Cemetery Address
Ej
Reinterment
Date i Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homet1cynar 8 ---0, 1 :k_ker I,--,crc ` iionr -- I 0 ! 9 `-ic1
- -
Address
I} t akky>z -H � . , t k_k_c c nsvt y , ti€ v� y(.3i- V 12 si€ -=v •
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above _
2 Address
CC
of
0.` Permission is h reby granted to dispose of the human rema desc ibed ove as indicated.
Date Issued 5//0 /It Registrar of Vital Statistics !\_
(signature)
District Number 'j 7 ) Place T6/2jy.\ Q f Y (,/( q
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.LU Date of Disposition_ 1'-1\-\\ Place of Disposition Pot 1[21.3 G0%4/t"N
(address)
w
I
IX (section) llotnumb (grave number)
OName of Sexton or Per n in Charge f Premises _ 7L-1.,ppL(
(please Z print)
111 Signature Title Ca t�mr�ZL-
/ (over)
DOH-1555 (02/2004)