Grillith, Arlene - -e " -I' I `16
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial Transit Permit
Name First Middle Las �,0 Se
i>i Date of Death Age If Veteran of U.S. ' ed Forces,
fr//�f// c1 War or Dates ,/ftD
Place of Death ,----' i /> Hospital, Institution r
City, Town or Village l vat-./E'_ Street Address C„e.. .et.-::,�� �.0-7 i-e� "
0 Manner of Death Fedaural Cause ['Accident ❑Homicide E Suicide ❑Undetermined ElPending
LEE Circumstances Investigation
U.
tu Medical Certifier me Title
i irk
• Address j
iiki Death Certificate File District Number Register Number
!> City, Town or Village i - ,�c>,4b4� ' ' _ S'jS(c g'
igii❑Burial Date / Cemery.or Cre a ry
❑Entombment 0t iG'n'Z -4�% 4-7rlaZzz-1‘07--._
n:i /
Address
``XCremation C / (Z—- 4)„,e, --� e , '
Date Place Removed / /
Removal and/or Held
='
and/or Address
to Hold
0 Date Point of
I0 Transportation Shipment
e by Common Destination
Carrier
ni
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
>< Permit Issued to - Registration Number
Name of Funeral Home _ ,,.4_ �t = R.ea.'_, G 7S
Address _
da-ii a
Name of Funeral Firming Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
IX
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A` Permission is hereby granted to dispose of the human remains des ibed ove as indicated.
Date Issued 0 4'D(c 'dn II Registrar of Vital Statistics CAM")
(si nature)
District Number SITS-(0 Place —lbw,* \/+ILLC
gii
;.;_>;: I certify that the remains of the decedent identified above were disposed ofin accordance with this permit on:
la P Dispositionnt V �ttomcif orlu
▪ Date of Disposition y-l�11 Place of � t�� ,,
1 (address)
Cr (section) (lot number) (grave number)
0
Name of Sexton or Person in Charg of Premises a r,,'foci/.,r iemalf
2 (please print)
Signature �'`' '1l� Title GQ(1l'?trO ,
(over)
DOH-1555 (02/2004)