Lehoisky, Elizabeth p
NEW YORK STATE DEPARTMENT OF HEALTH # 7
Vital Records Section Burial - Transit Permit
Namee.4 ` Middle jeg_co.L.:s_t,Di,st, ee:onetegeo
Date of eat � A e If Veteran of U.S.Armed es,
S0/6 95/ War or Dates At
Place o eath Hospital, Institution or
City, ow •r Village #fiRr/ of D Street Address 4,196 CB/9!DWJ';,/C RMAe 'QQO.
Manner of Death irgNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name r Title
Address
7 9 No l?T-jl 27{ 611RA/v>L4.4/41 47 P-
Death C ificate Filed # District Number Register Number
City ow r Village f/k rice R p S- ..S"9
❑Burial Date a Cemetery or Crematory f
❑Entombment 114--- /C G')/' 6 Pia .-1//�-W d z)?74 7 c ts'/t//,i
Address
Cremation C'/EEj/S►8C(,Ry,Date fY.
lace Removed
El Removal nd/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ini2,V OJ/ F a/46,'0i9h Meer'» 0/1/
Address
/P c:-E'O '66 Q7',FoRrA1/aNy, i d'
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem i des ribed v s Indic ted.�1� (�,�
Date Issued 4,--/GP 16Registrar of Vital Statistics 0 1 �'"`L
(signature)
District Number 5 76— Place-re co ✓ f'��� - jG, e
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1/fii/j, Place of Disposition nz11-. e 0a.,
(address)
(section) jot number) (grave number)
Name of Sexton or Person in Char a of Premises fot
.Mkt._ _tw'tN"
(plee4se pnnt)
Signature a Title CiLe NOV
(over)
DOH-1555(02/2004)