Meissner, Elizabeth # 75I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section " ` ' • Burial ® Transit Permit
Name First Middle Last 4 Sex
Vi G'Lt2 t9-et:h/ LouiS6,'" itie:i s5Ai e2 1 Fe-A/01-
Date of Death i = Age If Veteran of U.S.Armed Forc -s,
/o //fo�/to i 7.R. War or Dates ,J1/J
• Place of Death Hospital, Institution or City, 7.0:or Village Q tJ ,v. t? Street Addre /Z Li A.) E-7-rtr- Z40\A1 a�
® Manner of Death Natural Cause 0 Ac dent n Homicide 0 Suicide Undetermined Pending
W �t Circumstances Investigation
la Medical Certifier Name \ rb Title q�
P J.) �I i 0 l�U,,r� t A.) 4'Am.,y /7 b
Address i
3 ..l QA .1 c try C e-A J(y'Vl_. C (.ktwJ s FO-u-.S) A/
'» Death Certificate Filed pi ict NumberRegister Nu ber
City own Village o 6 ,OS r C �S I1 a--)
» Burial Date Cemetery o remata ']
Entombment /0 // - i/Co Y !,.J i 1//b'
Address
remation
-`` Date Place Removed
ZC Removal , and/or Held
2 and/or Address
E Hold
t/a
O ' Date Point of
cek C Transportation I Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
` Reinterment Date { Cemetery Address
>� Permit Issued to ,`� fRegistration Number
Name of Funeral Home t '.�%%C_t' \--t1 L, ;� O{\ \ cc t.. cc
Address
r
kk L,Say —4- C; i✓ 1�.� 1 , \y ill:aLt
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
CC
LEI
Permission is hereb granted to dispose of the huma remains describedd ye as indicated.
Date lssueei iII Registrar of Vital StatisticscG� Q .Q/b r\--,..,_...
_ (signature)
District Number c v- Place ( �� 6.6 C... . Lt....12s,,v,
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition PIM hi, Place of Disposition •ri,A✓ ( r
2 (address)
ill
fil
E (section) i(lot number (grave number)
0
• Name of Sexton or Person in Charge, T Premises 4/�(S1 a.�n di41 iyi �/ (p! ase print)
Signature L°� ' Title eaMeW
(over)
-
DOH-1555 (02/2004)