Wade, Sarah it
NEW YORK STATE DEPARTMENT OF HEALTH 0 '" AllZ )
Vital Records Section Burial - Transit Permit
Name First ii Middle Last Sc_ ' r
Date of Death Age If Veteran of U.S. Armed Forces,
J//o/ f 1 �� War or Dates
H Place of Death nn��.. Hospital, Institution or -�'''�'
City, Town or Village J ytd, ect..�x, Street Address (Oo P� 1 )\4
tilManner of Death 14.jNatural Cause ❑Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
ILI Circumstances Investigation
WMedical Certifier Nam y� ,t , _ Title
Address �1
1 0 c; Powi2• - ./r'-1-►^.d c=cc. --e-, -r. i a I
Death Certificate Filed District N&iber Re ister Number
City, Town or Village�il, n-Q,c S'( ,CD I 04 I 1
❑Burial Date C metery or Crematory
DEntombment Addre1, 1�' j �� ,
Cremation Q -NI". 1 y
[L Date Place Removed
❑Removal and/or Held
'At and/or Address
IZ: Hold
to
0 Date Point of
5❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home .6 Ux /o 9 g
Address
Ff Q ( A A-r 1?• e„,42,,,,A4 , t a- ft' ig-
Name of Funeral Firm Making Dispositio r to Whom
ji. Remains are Shipped, If Other than Above
Address
CC it/ --y\,, ern- ....i. - fi t. W-‹..., , L
ill
Permission is hereby granted to dispose of the human e ains scribed a ove as Indic-ted.
Date Issued S 10 1r Registrar of Vital Statistics --47
(signature)
District Number 5-L0 i Place Ai,9 4((5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Ilif Date of Disposition S=1t-l( Place of Disposition 3,N 1 tg� C+4,,dui i1.,,-
Ui (address)
Cl,
CC (section) (lot numb (grave number)
)
gt Name of Sexton or Person in Charg f Premises /}' ' of k_ t iwl-f-
Z '2 ' Y (please print)
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Signature Title C( I%h1� i v� _
J (over)
DOH-1555 (02/2004)