Henderer, Linda NEW YORK STATE DEPARTMENT OF HEALTH ,- . ♦ IF it.1 t
Vital Records Section / Burial - Transit Permit
Name First L1 Nt A fiddle NttiRgt-t Sex
TL-
Date of Death Age If Veteran of U.S. Armed Forces,
1? - 07 - jC1 tp2 War or Dates
};• P .ce of Death Hospital, Institution or
Town or Village�� g )1 Street Address JLJ V V fif4h,Dft-4 A-i.-
ill
ner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
ty Circumstances Investigation
tu Medical Certifier Name f"
0 �I ,PC1A-D �t-� f"V
Address
G,Db NOTTAK143 -v >, I Amy', y l 2:2,o i
•-ath Certificate Filed District Number Register Number
Town or Village j- ,A-,,v
Burial Date i 2 _ac.� 1' Cemete�v0 lr Ns V I'�-la.3 L W►A' t Ry
❑Entombment Address }� V y i
`; ` 1 Eremation CO CJJA164E-'U�` .� 3sstAw t i- c it
Date Place Removed
0 Removal and/or Held
and/or Address
Ili Hold
cAr40 Date Point of
liEl Transportation Shipment
a by Common Destination
Carrier
, Q Disinterment Date Cemetery Address
.:: Q Reinterment Date Cemetery Address
Permit Issued to (( �', Registration Number
Name of Funeral Home ► I`•�• M pi4L 3U t- C'�DWYE O 10-7cf'
,.:..:i:::
oi: Address / V cto
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
re
WA
Permission is hereby granted to dispose of the hu• an remain= described above as indicated.
iilii,li Date Issued E2-3--3d II Registrar of Vital Stati -
igi
(signature)
uli District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
Ili Date of Disposition Cu f,'�1 Place of Disposition (, zufr ,! acfpfiu�
(address)
in
CC (section) (lot number) (grave number)
Name of Sexton or Person i Charge of Pr mises ikua ipitr Js«eth`
z
(blease print)
, Signature ApL, Title 6Ih1}T0 -
(over)
DOH-1555 (02/2004)