Smorgans, Helen NEW YORK STATE DEPARTMENT OF HEA 5z(4
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Vital Records Section Burial - Transit Permit
Name Ili rs Middle rn P Last i S` 1 ta Le
� 1 If Vetera f U.S. Armed For es
Date of Death Age r�o
D --(Di- 1( D I j War or Dates CAR A)
}• Place of Death / ^ Hospital, Institution or
Cit Town or illage /oda ii LILKL- Street Address CflocA.,v frt Q.
O Manner of Death TE Natural Cause 0 Accident 0 Homicide El Suicide 0 U etermined �Pending
L1j Circumstances Investigation
W Medical Certifilat_ Name Title
Address U
ofao - 14/
Death Certificate Filed / --) District Number Register Number
Citydown)or Village J' .( ¢t,f, S ct. -K,
iii❑Burial Date 1� C eteryorr Cremat ry
❑Entombment I V 4 I1 ( tAili Y t k� CAI il(120-0-1-j-
:,..!
Address
Cremation 1,tLEAL4.64- 1 )R1
Date Place emoved
k I—I❑Removal and/or Held
and/or Address
F= Hold
CA
O Date Point of
t Q Transportation Shipment
O by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to ) 4ryu _
Re istrat�nNumber
Nameof Funeral Home 1 1,( LLQAI tAtAQ o /J 1
Address ( 35 7 e 36 \ X-Ci(1t--,K ( ,/Jte_ :y mg-tic)-
,:-.•:::„
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address .
tr
12' Permission is hereby granted to dispose of the hums mains describ- •• above as indicated.
Date Issued )0 oZ-f I I Registrar of Vital Statisti s ,t j a •/%l %/JJ py�
lI
(signature)
District Number a 033 Place ��,wyti?) att1J4.C.A-"- -1Ke
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
itl Date of Disposition to J IT fit Place of Disposition Ps4 0ik, (.-r+m clot•��
2 (address)
1i1
CC (section) (lot number) Clo.iti-
z (grave number)
0 D Name of Sexton or Pers n inCharge of emises Cj v.,4 I iirrit,
lease print)
Signature Title Cf rThrt0l—
(over)
DOH-1555 (02/2004)