Curren, Leona NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section `1 _.4 Burial - Transit Permit
—
Name First Z Mildle itill.,6 Se
Date of Death Age If Veteran of U.S. Armed Forces, ,
w/244f( War or Dates /LI rt-
}- Place • `-ath Hos , t on or
W City Town,i r Village Q Uf" r:�t7(} tree ddr S A,/C-#Kh4/0,1 is-...) ,
Q Man - • Death Natural Cause 0 Accent 0 Homicide 0 Suicide EjUndetermined ❑Pending
W __ Circumstances Investigation
W Medical Certifier Name Title
a _
Address-___�_.__._�____
Deat ate Filed District Number I R s er Number
Cit , Tow or illage ` l) �ct3 Q �0�
❑Burial Date Cemetery r Crematory
❑Entombment f 2-P L.4 i l
Address 0 421 lX/' Uiar
'`Cremation --
Date Place Removed
t❑Removal and/or Held
— and/or Address
—I- Hold
th
O Date Point of
C Transportation Shipment
Lt by Common Destination
Carrier
Q Disinterment Date 1 Cemetery Address
I Date - Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home t( n u ct . 6u�er Fury r o J o o 3) i 3C)
Address
i\ Q G.i e .}-H . � . , L.L.0 nSbt tr y , Ni E v.s 'yuf' L 12 U,--`
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above _
2 Address
tr
ti — -
tL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I O!1 Registrar of Vital Statistics "1-7:: -- 'Oce)fA,k-g- -
(signature)
District Numb rl Place ( C-) 1 C4 CD L-,-,_--> • )
t_ I certify that the remains of the decedent identified above were disposed of in accorda6eyth this permit on:
Z � (�
tii Ui I Date of Disposition foi3tIII Place of Disposition r.iIJ v Crr,,.4:6)(�.._
W (address)
U,
(section) (lot numb (grave number)
CI Name of Sexton or Person - Charge of emises _ L " A-1)1 r -)►ou'
Z (please print)
iLl Signature _ Title _ C129410
(over)
DOH-1555 (02/2004)