Miles, Sandra NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Tran it Permit
Name First Middle Last Sex
rue L. ir►► 2. PS cern rn le
Date of D ath Age If Veteran of U.S. Armed Forces,
i 1��-�` ►b rj I War or Dates
PI e of Death Hospital, Institution or
5 City Town or Village `era;, S c iY. Street Address I y to nZPrt v0c D e 1 J Q
anner of Death Undetermined Pending
►4 Natural CIse Accident 0 Homicide 0 Suicide
lif '—'Circumstances Investigation
La Medical Certifier Name Title
r j �,1. ti 1e f -iL RPAC
iii '' Address
11.11.1! /4 I cirk. 6r u 1a &O Y
<`I a th Certificate Filed District N6mber Register Number
<s Cit Town or Village Sc -a. A Sc„r, 450 I
0 Burial Date Cemetery or Crematory
t�ia-5 Ito ]7Itot vl Gctmc—e1y
ig.i ❑Entombment Address
ElCremation (I W#ers.1 act r n y _
>_ 7 Date 6 Place Remo' ?d
❑Removal and/or Held
and/or
Address
b Hold
0
0 Date Point of
1 El Transportation Shipment
fl by Common Destination
Carrier _
n.sj>Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home V.,11 (Ita,,,,, E
. ig(,iig 0 5OVn3 14 Gt 8a7
Address
iiiigi: (0 a$ 1\101Q+v1 8 coy, a.� ck r c—oc 5 r-►n S r)y I zAca,
Name of Funeral Firm Making Disposition or t Whom
Remains are Shipped, If Other than Above
Address
is
if .
Permission is hereby granted to dispose of the human remat_, cried above-.as indicat d.
�F
Date Issued 11 1 b ((o Registrar of Vital Statistics " 7 "
(signature)
District Number L.1cO ( Place �ek � � pc.t
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition n/ZS)i(, Place of Disposition rtAi 647Pcki. .
(address)
CS (section) jf(lot number) (grave number)
fla
Name of Sexton or Person in Charge of Pre ises ills /.. 3i'"'lt
if-
141
,vt (ple se print) r�- y
Signature �d'i Title C t4 I Z L.
(over)
DOH-1555 (02/2004)