Ryan, Pamela NEW YORK STATE DEPARTMENT OF HEALTH L7
Burial
Vital Records Section - 1ransut Permit
Name First MiddleLest Sex
. r; Date of DeathAge If Veteran of U.S. Armed Forces,
(`���? Z.fj i(.o c�2 War or Dates
}» PI ce f De th Hospital, Institution or /{� �_r ��� ,�
We ity Town or Village �7��`� Street Address A(ban j Me�l�l �,ott--
Manner of Death Natural Cause40 Accident ❑Homicide 0 Suicide ndetermined Pending
L Circumstances Investigation
tu Medical Certifier Name Title
D i tCAs h r D e-OCD i-eA 14k. S
Address
L3 /UM)sc tfo d give— ,4f q / Ny I Zzv�s
Death Certificate Filed DiStritt Number Register Number
ity Town or Village bol-f 1
Burial Date 3 Cemetery or Cremato
❑Entombment D I` [ZI � p-, vLLu) ( ruwb--i-or
Address
pCremation %e2ytL 6b`t--k'� /
Date J Place �
kemoved
Removal and/or Held
and/or Address
Hold
C Date Point of
Transportation Shipment
C by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iag Permit Issued to p� Registration Number
Name of Funeral Home ( rJ 1°U IMe.,(- o/c) i-$
111 Address
13 /Matt/ d-. 50. '(ens- .)1S , Mj ) 28b�
i Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
UI
Permission is hereby granted to dispose of the h sn emains described above as indicated.
Date Issued 32.i ( / 4 Registrar of Vit is ii
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition 3/3) J lb Place of Disposition giVt,,.i C ► w4ty
2 (address)
W
0
CC (section) / (lot number) (grave number)
Name of Sexton or Person in Charge f Premises 6L 6& l 1 S
2 (prase print)
Si 9 nature Title
(over)
DOH-1555 (02/2004)