Langdon, Bonnie 4
1- _ # 5 O
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
P)Or) n i Q T3 La In cq a -).0.1
Date of Death Age If Veteran of,U.S.Aimed Forces,
-6 /(O -7 3 War or Dates ILJ d
j- Place of Death Hospital, Institutio5v/eJ)5I;//s
r
� ty, Town or Village 5 Ct its Street Address 4-/j5,� )*
0 manner of Death j Natural Cause D Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
itiCircumstances Investigation
tii Medical Certifier Name Title
G AS r{ sC15 M
d�eeath Certificate Filed �/] /_/ District Number Register Numbej/
City Town or Villag / s ) L1.S Zo/ 1p9"I
❑Burial Date etery or C ematory
19 /(� rye View artmCit
El Entombment Address p
1,Cremation iLe ns iv
Date -Place Fayed
2❑Removal and/or Held
and/or Address
IF . Hold
to
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to ---- Registration Number
iW Name of Funeral Home r e }fr 4,,,,,,,22f 4 yy1j /i eod-1/
Address
u rr4 S� Z La 7] /20 &
p
Name of Funeral Firm MakingDis os tion or to Whom
}. ` Remains are Shipped, If Other than Above
2 Address
it
ILI
it
Permission is ereb granted to dispose of the human rem 'ns described a ove as indicat d. f.
Date Issued q Registrar of Vital Statistics -- _, . /- . (',/'—C.
4.---- (signature)
District Number 566 ) Place 6/6nS //S
I certify that the remains of the decedent identified above were disposed of. accordance with this permit on:
iii p it Place of Disposition /►
Date of Disposition Oil 6giv,a......, Crw-c-fw—
(address)
Lu
0
IX (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises t'( �c..
2 please print)
i:iB Signature v" Title CA
(over)
DOH-1555 (02/2004)