Newell, Jean c 1
NEW YORK STATE DEPARTMENT OF HEALTH $sb
Vital Records Section Burial - Transit Permit
A
Name First iddle Last 1 Sex
in Date of Death Age If Veteran of U.S. Armed Forcest'ild-•
iiiii (1 t &R Iaolu 60 r Dates APlace of Death Hospital, stitution or
.City own or Village 51.ens Fcou ree ddress �l en s (-ci .. -k sp
� Manner of Death Natural Cause Accident Homicide SuicideLiUndetermined ri Pending
tAl Circumstances Investigation
Medical Certifier Name 4 Title M l
0 a u 6,6-4. Q 1 c 1,9,,J i
Address A r. I���
/ b Z P&Yt4 ?T-, C'Ltr.Js Fps , A /
'-.th Certificate Filed uol
District Number Regis b
own or Village ( /4 A) S' CS _ c
Date Cemetery or rematory n \ /
CBurial I I//2 / eP rI(\-t V1 €t*j Y y1 1
I 1 Address '
Cremation �. kU t t_0 QPN IQ Liar"k laical
Date 1 Place Removed
Z C Removal 1 and/or Held
2
and/or Address
Hold
Q Date I Point of
3a0 Transportation Shipment
fl by Common Destination
Carrier
::: Disinterment Date Cemetery Address
.. C Renterment Date Cemetery Address
<; Permit Issued to _ Registration Number
Name of Funeral Home __ _-8 p WI, -u,j4-r MN 4 0%/3Q
Address / {`
Ay, /2.,:pf.„ ft
Name of Funeral Ffm Making Disposition or to Whom ri 1
pp
Remains are Shipped, If Other than Above "
Address
II;; Permission is hereby granted to dispose of the human re ains de cribed -bove as ind' ated
i Date Issued i I ", Oldie Registrar of Vital Statistics �`I r _ /�- /r
(signa •re)
A..7".___.
<:3
Mi District Number *4;' �0 i Place ..,......"4,_„1/1_.
I certify that the remains of the decedent identified above were disposed of in accordance aal wi this permit on:
f; pp
Date of Disposition It12 I It Place of Disposition 'I�nzUN.) i(Oato(+a-
2 (address)
IVJ •
CC (section) , lot number) (grave number)
DName of Sexton or Person in Charge of Premises l�r1i 3iaill( "
z (please print)
W Signature �( Title OE tileryi.,
(over)
DOH-1555 (9/98)