Howe, Teresa NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs Middle il yLast Sex
ere 3 �✓�
Date of Death Age If Veteran of U.S. Armed Forces,
I l l /a v 17 V War or Dates
1- Place of Death Hospital, Institution or
,.� � own or Village 5,,r\+05 5 ,� Street Address -5"r v"/`T., H" tk
... ,anner_ of Death Natural Cate Ac(�ident Homicide Suicide Undethfmined �❑Pending
® Circumstances Investigation
ui Medical Certifier Name Title
-berg-- P Lc— KO
Address ,>r•t-l-or )-+=r ci.....0a. vt-, -C-,f---1-7. NT
D ertificate Filed District Number Register Number
CI wn or Village 5 r& y 1f5-°1
Burial Date U Cemetery or Crematory
❑Entombment ` / 3 a. i7 ilcV, 6�µ1��
Address II c Cremation 67,A, _c, (,,.,.. lj
Date � ) *� l
Place Removed
Z Removal and/or Held
and/or Address
F= Hold
to
O Date Point of
Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Eiii Permit Issued to — Registration0't Number
ry
Name of Funeral Hom G �5..-t�rc "�,�er �.�
Address
5'46M6,— t �, � IQ 'I' I � )�
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
re
to
Pl. Permission is hereby granted to dispose of the human remains dscribed bov`e' s indicated.
Date Issued I / 17 Registrar of Vital Statistics `--., 1
- -4-Eitat/na
(signature)
District Number ti-Sci Place _______S;U.447.34 p )J Y
I certifythat the remains of the decedent identified above were dis sed�6f in accordance with this permit on:
ILI Date of Disposition 1)3 I lb Place of Disposition -Pivi Vc.,./ L f cf e,,,
a (address)
UI
to
t (section) /i(lot number) (grave number)
Name of Sexton or Person in Ch rge of Premises �A vihiL, 31,4;47
(plea a print)
1:11bR_
J Signature 7:( V Title i'^'6
(over)
DOH-1555 (02/2004)