Baby Jane Doe, Fetal Death-Confidential J ;,j Z
NEW YORK STATE DEPARTMENT OFHEALTH ����,�U � ������� ������
V�dRecovdsGeodon _ ��~-. n~~n Transit Permit
Middle a
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Date of Death e?Age If Veteran of U.S. Armed Forces,
L_ war or Dates
j; Place of Death Hospital, Institution or LA
City, Town or Village Street Addres
El Undetermined Pending
Manner of Death Ej`Natural CauseF Accident 0 Homicide Suicide
Circumstances Investigation
Medical Certifier Name. Title
Addres
i C A kq-x)
j Register Number
ath Certificate Filed Number
Date CfNetery Vremato
D Burial
Address
Removed
Date Place
Z F�Removal and/or Held
and/or Address
Hold
Date Point of
I Shipment
Transportation
by Common Destination
Carrier
... Datb Cemetery Address
F�Disinterment
Date Cemetery Address
Reinterment
I ued to Registration Number
Permit ss
Name of Funeral Homeh -P�1. VjLt0%-L &A-rr� 'Poole
2- WtV745
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
`2 Address
- Permission is hereby-
ranted to dispose of the human remain
Oate \ssued ��-�^�m�� Registrar of Vital Gbatiaduo
District Number p)mue 4V641W Y � ^»rm�
| oe��v that remains of decedent identified above were disposed of in accordance with this permit on:
- [� �° `
Date of �-|\-�\ Place ufOisposhjnn ��/r^U/.� �.r*��f 0°'�~^
(address)
(section) _ (Ioj number (grave number)
Name of Sexton P on in (�h Premises
~. _"- �
(please print) _
LL Signature v/ Tide �e� yl/��a�~
= ' ..�.~- ,- ~-~�. °
(over)
DDH'166G (0/98)