Ross, Lucia /3
NEW YORK STATE D ARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
A. Name First , Middle _-fast S�
LUcI 0-- ►-ccs5 1 r►/A /
Date of Death Age If Veteran of U.S. Armed Forces,
U 1 (0 /go/(p Tr War or Dates C
I- Place of Death -}— i Hospital, Institutionior
z City, Town or Village X0 4 NS P C� r1 Street Address Adore IJ dALKC 1 1.6, J11 vh4c N c /4�ilt..(_,
p Manner of Death i' Natural Cause 0 Accident ❑Homicide 0 Suicide 0 Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
A s F ditkud se ,4./ Fri0
Address / R + ` O -(,,, D it )Q y' / �� ��
11� Sfi i' l3Qc�,l �Y �'/1 Cv
• Death Certificate Filed / District Number Register Number
City, Town or Village A c✓1)lam' h(,)�9 ��Q �. a -
❑Burial Date V^l / 0 n/ ,// Cerptery or crematory -�
Entombment ! JAM-0/Q et) �' heim A 1 e ir y
Address
}*-remation 0 ic.2iiUS bwv.x. i / ZgO'
Date Place Removed
Removal and/or Held -
•
2 �and/or
Address
+ Hold
0 Date Point of
05 0 Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
PermitameIssued tora C a v-a. F 1 % f I /_% Registration Numb r
Name of F eral me 1 f� (�J tJh t rA( `)'G Ci V �!
Address
C' I. POVM- i- IN. /2•0-- i _).),/: / -)()
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
it
L
P" Permission is hereby granted to dispose of the human remain escribed abo e as ind'c ed.
Date Issued /- - 1 (p Registrar of Vital Statistics jc) q ,
(signature)
District Number 5-4Place 0.t�� J6h u
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
P
ta
P Disposition /Ds�Q 1J� if ) 1---fa_0 0 ..iloc/
Date of Disposition /- -/ Place of
2 (address)
Lu
U)
Ct (section) /gof number) (grave number)
Name of Sexton or P rson i Charge of Premises I c.c/,`&✓a L2'JPl4l.4e
(please print)
lif Signature h�%`-' Title 6-fe a- o.�
(over)
DOH-1555 (02/2004)