Hussa, Carol NEW YORK STATE DEPARTMENT OF HEALTH If ' ' 6)
Vital Records Section Burial - Transit Permit
Name First ear i p Middle �S Last Sex
I s0,- ,-1-
Date of Dea h �� ��f Agee If Veteran of U.S. Armed Forces,
War or Dates
I-- Place of D ath Hospital, Institution
W City, Town or Village����,fIQQ.J(S�,(A Street Address t �� cgrA,
0 Manner of Death(I"Natural Cause A�cident' Homicide Suicide Undetermined Pending
W '`t' �Circumstances Investigation
ill• Medical Certifier/��N�arpe� C'�x� r �� Title
0 1N I
aAddress
\K.u.imou.\\Ith
Death Certificate Filed District berms., Register Number
City, Town or Village �� i( q
❑Burial D i'r Ce ry or remator
❑Entombment tQl*: c3 ( 4 Ii k b
AcIctrqs Cremation Cd P r k_f)
Date / Place Removed I 1 ny
Z.: ri❑Removal and/or Held l
and/or Address
til
n- Hold
Date Point of
05❑Transportation Shipment
CZ by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to ` I Registra on Number
Name of Funeral Ho I\\JQ-(1 i-Hcir.'
015V L
Address
3% W--Q_MICklA .?1/ /21CW
Name of Funeral Firm Making4isposition orito Whom l
t
• Remains are Shipped, If Other than Above
2 Address
C
LU
'` Permission is hereb granted to dispose of the human r n dens ' eabo indicated.
Date Issued Registrar of Vital Statistics (� J(�.,
(signatur
District Number5(05t7 Place "
) 1 n 1....::..:: I certify that the remains of the decedent identified above were disposed of in acco ance wit this permit on:
ILI• Date of Disposition Place of Disposition
', • (address)
LEE
to
CC (section) (lot number) (grave number)
aName of Sexton or Person in Charge of Premises
2 (please print)
lit Signature Title
(over)
DOH-1555 (02/2004)