Schuler, Patrice NEW YORK STATE DEPARTMENT OF HEALTH G ` 3
Vital Records Section Burial - Transit Permit
Name First Middle ast Sex
tA�l e e- b • o,v 3 e/ a c t,l t Y i-v, �-
Date of Death / Age If Veteran of U.S. Armed Forces, ^ j
C8—c�- get' /91 War or Dates - O
I-. Place of Death Hospital, Institution or
Z City, Town or Village 3 Gl(Z7`e f•J c,Street Address cc V_S /?7
Q Manner of Deatia atural Cause ❑Accident ❑Homicide ❑Suicide ri❑ Undetermined Pending
Ili Circumstances Investigation
Or Medical Certifier Name ` Title
L $A ha 7 / ip 54N �' P
Address
"/ raoirFi'e. f A &w-., 5-CI ►-crr 4 6A tG kU7. /-€S'70
Death Certificate Filed District Number Register r( er
City, Town or Village eSc4P 3 /b
0 Burial Date Cemetery or Crematory
Entombment Address
Iiittremation 00 Q,klos b vfr,, jfkir
Date Place Rerfioved
Z❑and/or Address
Removal and/or Held
C.'
Hold
0 Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date ' Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to (.�'���� ,/ a/ Registration Number
Name of Funeral Home L�d`G+-'A►� A,10_41vde rn I Cole �S'/7
Address — ,/'- / i-7t
:.,,,.„, C
Name of Funera Firm Making Disposition or to Whom
_ Remains are Shipped, If Other than Above
Z Address
Z.
iU
Permission is hereby granted to dispose of the human mains described above as indicated.
Date Issued OF-at y-951 Registrar of Vital Statistics )- 'LL 5a 46 U�/(;.0
" (signature)
91
District Number /563 Place �' ,� /, 1, f
vvvYYy!!! '�
'::-:- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition if Sift, Place of Disposition ct,i. ,r Cthwi tv.._,
2 (address)
LU
Cl,
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises (AN St1"4'F-
(pl ase print)
iii 'a_ 4:4-
Signature - Title G0441 -
(over)
DOH-1555 (02/2004)