Loland, Joyce it /3b
NEW YORK STATE.DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death / Age If Veteran of U.S. Armed Forces,
S/ f /4P 6 LI War or Dates tV/A
p- Place of Death Hospital, Institution or
City, Town or Village toga Spier l$ Street Address /d /1 VL AO /35-
ul
W Manner of Death❑Natural Cause Accident El Homicide Suicide Undetermined ®Pending
Circumstances Investigation
lEl Medical Certifier Name Title
Q 306 if ML x fogolkt
•
Address
VI ?° kat ROAD q Kite IN. iag®1.
Death Certificate Filed District Number Register Number
City, Town or Village 3d i�a.1v C 41 4/1/c7
❑Burial Date ll//,^ Cemetery or Cre atory ,,� /7
Entombment ^l - w Pi N V( ti k-erYi k v
Address alCremation cl 1 (,t-CI,K rC-P.Gad, (D�EL��� LZ62.c� yo i I Jks
Date Place Removed
Z ri Removal and/or Held
2 and/or Address
t- Hold
U/)
0 Date Point of
95 Q Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to / Registration Number
t 11
Name of Funeral Home (c m a,�5 rvl7��-1-C Fa pp4(�l( Gj 0- do i
Address /v
4,0 d') ale A v-. , J.iza lor Jp l'Alv, W V l dze&
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
Address
tr
lu
4` Permission is hereby granted to dispose of the human remains desc 'be abovea ' icated.
Date Issued a//3//f, Registrar of Vital Statistics
(signature)
District Number L13 b ( Place 3a ieztkg J' / 1„5 I A) Y
i_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g Date of Disposition Z/7o JR, Place of Disposition ?t�,J,a.i (r^„1-(of,�.—
W (address)
(l)
CC (section) n (lot number) (grave number)
pName of Sexton or Person in Char a of Premises lyrist SQM +
lZ ( lease print)
Signature Cc Title A4t1OL
(over)
DOH-1555 (02/2004)