Holland, Priscilla NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Mee Last Sex
r:x.. 1(,� H 3 II au-k , -F-
Date of Death Age If Veteran of U.S. Armed Forces,
7/aI / /6 75---- War or Dates
} Place • :-ath Hospital. Institution or
Z Cit, , -own •r Village Street Address it 7 at Y /o ) L,t--sg
0 Ma '. Death Fif. Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined — Pending
—Circumstances — Investigation
W Medical Certifier Nara Title
Address
[ e reer. '-1 L PAiligi•t Av 9+. i a2)1a.Z
Death C ficate Filed 0 ' District Numrber Register Number
- City:Town Village C r.. '7533
Date Cemetery or Creme ry
Burial 7/ //6 < ok e f.e.:... C, 'f-4--14,6
Address ALL...),
Cremation ��.ens�,,r j ) tV :a ,'(
Date Place Removed
O ` Removal and/or Held
H and/or Address
Hold
0 Date Point of
0 —Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
— Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Ho e_a5 f� .),,-- aCI"t r I
Address
—7 germ.... Ave CE, 107 ►a)Sax_
Name of Funeral Firm Making Disposition or to Whom
�' Remains are Shipped, If Other than Above
rri Address
' Permission is hereby granted to dispose of the human r: • • :scribed ov: •s• •icated.
Date Issued 7/a�..�/4' Registrar of Vital Statistics Aga?
111"7,a •re)
District Number 't5-53 Place r. I / 7
I certify that the remains of the decedent identified above were disposed of in acc rdance with this permit on:
Date of Disposition �l LOLL Place of Disposition 2 ct,-) an.A.__,
w
m (address)
U.I
0
CC (section) (lot number) sill (grave number)
d. Name of Sexton or Person in Char of Premises 4j
Z (please print)
W Signature Title alrevqft-
DOH-1555 (10/89) p..1 of 2 VS•61