Edward, Lydia 1(33
NEW YORK STATE DEPARTMENT OF HEALTH BUrIa( - Transit Permit
Vital Records Section m i
Name First of Middle- Last ()A, n Se,k,�/
U) CII LC � 4�-c- `
:! Date of Death v , Age if Veteran of U.S.Armed Forces, .
- ?,0, 1‘ War or Dates �t ,,
Place of Death Hospital. Institution ore "V �3 �/®
Z City, Town or Village ()uv,, _ Street Address es Wvz-'t'el--
LO-
Manner of Death Undetermined Pending
Natural Cau [�Acet ent �]Homicide Q Suicide
Circumstances Investigation
Medical Certifier Name - Title
Address /, y� r� Ili
:>„^ fly / ( r J
3 Death Certificate File (� District mber Register Number
til City, Town or Village l 4 S) 7
Date V Cemetery or Crematory
❑Burial - 3 u— ()Olt ;n f iJ 1 V w &V,Pi c/1,
Address •
::::: LIP Cremation r . U e 14 (/j!/(/L (lei .
Date Place Rdrnoved
Z Removal • and/or Held
rand/ora Address
Ell Hold .
0 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
`? 1-1 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
IPermit Issued to Registr Jtion Number
< Name of Funeral Home '�': A V)�/.���G� 70 k,—-i�1, D 03 U
i
Address. . c
Name of Funeral Firm Making Dispoitio or to Whom
" Remains are Shipped, If Other than Above
Address •
;
Permission is herebygranted to dispose of the human remains descri ed above as i sated.
. 1P d!
A.
Date Issued R-3)- Registrar of Vital Statistics k � )/A ---
M (signature)
•
i �5
District Number g1 Place (1),4A___Ei •
I certify that the remains of the decedent identified al3ove were disposed of in accordance with this permit on:
F
Date of Disposition 9 it lIt Place of Disposition T 'at Uku i �rv►�wftvL
(address)
•
(section) r (I number) r (grave number)
gn
oS Name of Sexton or Pers in Charge of emises i r, r Je rift
G L (please print)
Signature
Title R 041111.4
(over)
DOH-1555 (9/98)