Snody, Patricia NEW YORK STATE DEPARTMENT OF HEALTH . "` li
Vital Records Section Burial - Transit Permit
IMIIMIIMINII
Nam First Middle Last Sex
Date f eathL (a_ Age If Veteran dt U.S. Armed Forces,
iiliiil 1 ' i( 73 War or Dates (\JG
Place eath Hospital, Institutio or�
City, mow or VillageY1 Street Address
Manner of Death L7N1771Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investigation
M• edical Certifier Name Title
A&- t- G-/Lt4,,./ M I>
Address
GV (L ' NJ
Death Certificate Filed_ District Number Register Number
isli City, o" or Village 7 j- C ee.,K,
Date �'etery�pr Crematory
EllBurial f 1 0 1 1 `f'I U t,Gt0 C./`f'yy(Q 72- `
Address
Ei Cremation
Date ) Place emoved
g a Removal and/or Held
•r, and/or Address
Hold „
9. Date .Point of
thi 0 Transportation Shipment
a by Common Destination
Carrier _
Disinterment Date Cemetery Address
:.:: Reinterment Date Cemetery Address
Permit issued to Registration Number
'` N• ame of Funeral Home �> ,e,r---t,c &k +-1-nyyLe I r c a O S
Address ))
"' Name of Funeral Firm Making Disposition or to Whom
E. Remains are Shipped, If Other than Above
Address
M
;1
iiiR Permission is hereby granted to dispose of the human r ains de 'b d abo dicated.
iiiiiiiii Date Issued 1,)1 D\l1 II Registrar of Vital Statistics
__ (signature)
>< District Number Place 1t` i,Uy1 O(' y)L,1 C ,E 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 D• ate of Disposition TOWN 1Z‘1010Dlace of Disposition 2„,,u at•/ C ali(.,
2 (address)
tIJ
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f (section) (lot number) (grave number)
Name of Sexton or Person in Charge o remises0 (1(,s- l•P S,,,,fi"
z (please print) _!I
tL Signature Title CO EWI I G
DOH-1555 (10/89) p. 1 of 2 VS-61