Steady, Jane NEW YORK STATE DEPARTMENT OF HEALTI t' it 5"Z
Vital Records Section Burial - Transit Permit
1Middr . Name First
le Last Sex
Jane . N e,t�en S'f�ac�� F
=: Date of Death Age 1 If Veteran of U.S.Armed Forces,
11 12- 12O I to Sto War or Dates yv W5.-
Place of Death Hospital, Institution or Glens c'aa\r ( P kki
—OM&►• orVilkage Oleos. Fc ,tt,r Street Address (oo?alt s4. Gl.enr ccd i NL (2Voi
Manner of Death 21 Natural Cause 0 Accident Q Homicide ❑Suicide 0 Undetermined ri Pending
` ; Circumstances Investigation
. Medical Certifier Name Title
Scan:d A\nmed ?‘/N si c aY)
Address
Vtoo Part- S4-ret-!� (, j3\
Glens F&)Is, ) )v60)
Death Certificate Filed n District Number Register Number
ity Town or Village In)ern.S Fct)' ; 56 0 1 3 5
Date Cemetery or Cretnato /�
0-Burial 0-11 1 z 12C 1lO 1'1' 1nt I ct Crerna
Address
Cremation Date uaKt'.r 'Rd. Q PTa R)ei '�^� York /Z PO y
g Removal a "--
0❑ and/or Held
>tiaor Address
a
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
[i Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home `er Funec m Of}30
f e Address // / r
LQ culate at. , G?uss.nsb L ,AJely qv i lab'Uy
s, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
f'r Address
Permission is hereby granted to dispose of the human remains described above as indicated.
tom:
,.,.' Date Issued "'7 (1 2 / f� Registrar of Vital Statistics C-A-i-y�Q v^
i i(signature)
Or
District Number 5-6 v I Place 6 � Rik) I s , Id
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition "1 f 1 11(IF) Place of Disposition eirttOux.) C ,.,,.„
2 (address)
ILI
tti
(section) (lot number) (grave number)
Name of Sexton or Person in Charge Premises i
i e�
z g _ (please print)
14E Signature Title elf fiti Ole_
(over)
DOH-1555 (9/98)