Hagadorn, Sherry ft
NEW YORK STATE DEPARTMENT OF HEALTH 0 b3
Vital Records Section Burial - Transit Permit
Name First ii,w� .�Middle Last Se
of P`'j� ...� _ H G. q a a o r. u,1.,.LE.
I Date of Death ® Age If Veteran of U.S. ed Forces,
I a I .x '1 I),a t (gv War or Dates
Place 1 Hospital. Institution or ��
Z Cit •,Tow_�.vVillage '' ' Street Address 1-
15 Manner of Death V Natural Cause 0 Accident 0 Homicide E Suicide 7 Undetermined ❑Pending
U./ Circumstances Investigation
W Medical Certifier Name Title
CIt<:'c,1i.e,r,k Le A+ „ /4 • .
Address
. Death ate Filed District Number Register Number
CI ,Town Village C .r.
Date Cemetery or Crematory
._ Burial ( a / 6 / A a it 74 eV ,t:,-+-1 6.^ fy�
Address/ I/
Cremation UC"� 'A.SJut Ak....-
Date V Place Removed
O n Removal and/or Held
F- and/or Address
Hold
Q Date Point of
NTransportation Shipment
Ea- by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to N Registration Number
Name of Funeral Home e. ,^,5,�,�5,c - r..�. R ^�-, -.Lc_ OO $
tiny
Address
S4crti,4- ,-VC c - A ( C- �d..t.
Name of Funeral Firm Makin Disposition or to Whom / i I
" Remains are Shipped, If Other than Above
Address
14
Permission is hereby granted to dispose of the human r ains scribed ov s ' icated.
Date Issued 1c)-- /.a 7d°iI Registrar of Vital Statistics 0(44 L
a re)
District Number
`'f 53-3 Place w, d .--an,, 0,...) i ar/'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i-
W Date of Disposition r)-)..c-.,x( Place of Disposition'i nett ew crema o'or--,
g (address)
LU
N
CC (section) i . 0 (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises t`rv,n rte....it C.
In
• (please printf
,4 &A
LLJ Signature Title Cr-cola-L-7 145,5
DOH-1555 (10/89) p. 1 of 2 vs-61