Snyder, Marie It 1
NEW YORK STATE DEPARTMENT OF HEALTH r 1103
Vital Records Section Burial - Transit Permit
Name MA
Ziddle AJ� / Se, A/,
//! cue y,- �
» Date of Death Ag If Veteran of U.S. Armed Forces,
C� S' ! /7— ?al/ War or Dates
Pla - - a:-th Hospital, Institution or
Ci To or Village 3 c/-ojhJ Street Address Scr fW%r AU<—
10
Manner of Death ► .Vii tural Cause Ej Accident ID Homicide ❑Suicide ri Undetermined ri Pending
it/ Circumstances Investigation
ill Medical Certifier tee
b-; Ae �r Title
Addres ay.
/
>` QCI 6 ,� 7 �Q 2- ES cc j ti�:,fC �.(_ �;vc»x�r+rq"A Iv 1
Eiii Death if))cate Filed / District Number Register Number
Ci Towy6r Village c-.M 1--0`d 1-� /c •
mi OBurial Date //.2._/.:3-e//
C tery or Crematory
n/�'iew° C'remAT-ci y
❑ ort�
Entombment Addresr7)
g remation --YJeetis Jo?' /A 1( r
Date Place Removed
Z ❑Removal and/or Held
and/or Address
tf
1`- Hold
0 Date Point of
;h 0 Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to r / Registration Number
Name of Funeral Home Ed-ty A.r, L - 1 .c_. ry ri a"al Wm-e oas—!9.
ig Address
/ 0 0
liHi Name of Funeral Firm Making Disposition or to Whorn
Remains are Shipped, If Other than Above
2 Address
IX
t1>
• Permission is hereby granted to dispose of the human rem ' described above as indicated.
i Date Issued 6 S///�'// Registrar of Vital Statistics 6' 1"��j,�p�� c1, �
(signature)
District Number 1 5103 Place C1, } 0-07 )� j
/`r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition ( a-it Place of Disposition PA, v,,...., ( ram�ur .,,,`
•
2 (address)
Lu
Ul
tr (section) -• (lot numbe (grave number)
O Name of Sexton or Person in Charge of Premises d i)ifivet-t r 1-
2 (please print)
• Signature Arkk... Title ari---i-,4T(7k
(over) .
DOH-1555 (02/2004)