Friend, Karen NEW YORK STATE DEPARTMENT OF HEALT# 11 4rmit
Vital Records Section Burial - Transit
Name First / Middle Las i Sets
(<A re l� 7^/e&.J e , rfr'7A/p
Date of Death Age —7 If Veteran of U.S. Armed Forces,
0.) .-- 0 7 .aD // j cP3 War or Dates Pe
Place of Death Hospital, Institution or
City, Town or Village fiLbd Gd/hhin Street Address 6-843 RI-028' A.)
.f l Manner of Death EINatural Cause ❑Accident El Homicide ❑Suicide IT❑Undetermined Pending
Uil Circumstances Investigation
Medical Certifier Name Title
o �vi'6 /AU r Pao — c--
Address _
L/ S f AN c,vi Dr-. /\/V-a.)c.onr /f. / 8- S''a--
`< Death Certificate Filed / ' District Number Register Number
City, Town or Village Ntdcon.d /557 (2_
Date Cemmtery or Crematory
❑Burial C. /08 bdll j V/ le_ !//Q-ul ehe4vA /01 /
Address
remation
a Cl e e 11S Jo u 1-y
Date r Place RertSoved
0-C Removal : ai_d/or Held
and/or Address
Hold
0 Date Point of
N ❑Transportation j Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Ho e 7dwA $4 i-,• C-0 6,verililote— �d
; ; Address 1 /
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LU
>a Permission is ho/er y granted to dispose of the human remain described • . • as i icated.
Date Issued 09 Otf'`owl Registrar of Vital Statistics Q�,(,►L
(signature d
District Number/..5 Place N of /V f '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 911011 Place of Disposition -P ru J _ (rtc±o(Iv,
2 (address)
i4J
CD
C (section) (lo number) (grave number)
GName of Sexton or Pon in Charge of remises „:S�T f hac�
Z (pleast)
Signature ('Jk Title C(Z /i hTOlL
(over)
DOH-1555 (9/98)