Parker, Patricia 4 7 " 60
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
')4� /0( Zo/ b S7 War or Dates /1l',
lac of Death r� Hospital, Institution or /
Cit own or Village l/d 0-lit f///,€1 Street Address ,7�Up , Xie�
Manlier of Death®Natural Cause 0 Accident ❑Homicide 0 Suicide El Undetermined 0 Pending
i Circumstances Investigation
iii Medical Certifier Name Title
Q
Address
th Certificate Filed District Number Register Number
City Town or Village �d �//� eLi d
Burial Date �� l Cemetery or Crematory
❑Entombment Address
/� ��iLG�i � �c�.
�` / �) //wed y
remation ZG _4 sd�'e1l ,�7
Date Place Removed
❑Removal and/or Held
and/or Address
H Hold
#A
C? Date Point of
05 ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to /� Registration Number
Name of Funeral Home (,G' /77ls 5-5"i ,,,,/4- `G� / .--i7c Co 36 V
Address
Name of Funeral Firm Making Disposition or to Whom
IS Remains are Shipped, If Other than Above
2 Address
#C
W
` Permission is hereby granted to dispose of the human re ins d.esc i ed above as indicated.
Date Issued iJf jJLo ) (, Registrar of Vital Statistics
( ign ture)
District Number l O3 Place ()I-Iti0 WOLF aV I-14_-f
,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 /'
LLE Date of Disposition I/is//6 Place of Disposition °t Up?✓ C m r„�
W (address) l
l)
IC (section) ! (lot number) (grave number)
Name of Sexton or Person in Charg of Premises ,, ►.. ,S6et+tti
tilease print)
Signature Title (10-A11.94
(over)
DOH-1555 (02/2004)