Foy, Rita NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First /I Mid a Last ____T-0' Sex--
1Date
, Cam-\ ' �G�,- L'-e
of Death , Age If Veteran of U.S. Armed Force ,
vs/ i9ioZ� it �� War or Dates
}•, Place of ath Hospital, Institution or
ZC• , Town Village , c_e 1 Street Address T s4--.4ti{"` t )'
a Ma Death ®Natural Cause ❑%ccident 0 Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
Ca
ILI Medical Certifier Name Title
elSl-k_ZU A -r_ Q Is,o A /\._1).. -
Address _ �-t
o
Deat eficate Filed D nct Number R ister Number
Ci , Town Village vc ' � --)
❑Bunal Date Cemetery or Cremat /�
El Entombment 0 S�/x5 /a r e V;4-,,, 6ca.1-}o;.,�
Address
QCremation Q�e-C ,., 5 b u r N L,., %a f!L
Date U 1 Place Removed
Z Removal and/or Held
2❑~ and/or Address
Hold
0 Date Point of
i 0 Transportation Shipment
a by Common Destination
IY Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home �kSM v rc_ „e r,(_ -1-}.."Me) 0 0 1-`1-2—
Address
7 ker,, A-
V Cr. N I Iga-,
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
#C
t
CL
Permission is hereby granted to dispose of the human remains describe above as indicated.
C�
Date Issue �� t l Registrar of Vital Statistics '�',� CI , 12)-, __
(signature)
District Number Place C___ .,.Q 1
4 A�,"
I certify that the remains of the decedent identified above were disposed of in acco da ce with this permit on:
z
LU Date of Disposition S-L3--t( Place of Disposition FLUB C('1i'clor,v—
(address)
III
11- (section) /1"/ (lot num r) (grave number)
Ct
Name of Sexton or Person in Charge o Premises C ^r -St.vitt
(761 (please print)
1 Signature Title Cit ti M A pia
(over)
DOH-1555 (02/2004)