Madison, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH , +I 7r 313
Vital Records Section Burial - Transit Permit
iiiig Name First Middle Last Sex
iiiiiiii Date of Death Age If Veteran of U.S. Armed Forces,
10Lk` Zc)tLp. g 2 War or Dates
'> Place of Death Hospital, Institution or
Ci , 1 own Village ( vx-,, Street Address ' -}p`c„,,.e 0g,t,
Man o Death.r4 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
J Circumstances Investigation_
Medical Certifier pName Title
Address
111 (.c04 '1 ctAtY\�Yr Pt3C� CSE)cii`c l 'i" 12S Z`Z
Death Certificate Filed District Number Register Number
111 City, • i or Village (a.),Ckr -\-&\ . �SC-3 T
Date Cemetery or Crematory
❑Burial 5`{5 l 1 LU R 14-le_\.)..,-c_c_i_, C A--eor]r,_' r c"
Address
fl Cremation C veec-IS�DUyc c .
• Date J Place Removed
fl❑Removal and/or Held
. and/or Address
g Hold
Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
::'::: Permit Issued to Registration Number
€� Name of Funeral Home �S ;j rt.1c.t.Arr,;,( 140..e. )-mac_ b49`f`�,
Address / .. , v
iii Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
iolg Address
W
Iii Permission is hereby granted to dispose of the human remai es ibed abG ye a ' di ted.
• Date Issued b \-S 1 Le Registrar of Vital Statistics t e _.
(signature)
District Number L-1t53 Place CQjri`C -k-wN c
I certify that the remains of the decedent identified above were disposed of in accordanceFf�� with this permit on:
W Date of Disposition Sf G fit Place of Disposition 4.t0r,✓ �, +,,--
(address)
UI
CA
Ix (section) (lottnum r) (grave number)
GName of Sexton or Person in Charge o Premises h �j►
z (please print) /
L.! Signature A, Title 47114
(over)
DOH-1555 (9/98)