Hansen, Agnes tlik # 36
NEW YORK STATE DEPARTMENT OF LTH
3
Vital Records Section Burial - Transit Permit
Name First Aiddle .4 Last f Sex
,cles v+Y� -\'l o.� e 1 r
Date of Death ( Age _ 'fir-tiVeteran of U.S. Armed Forces,
O`-I I i q / 201 u ( 95 1-' War or Dates N J a
1•- Place of Death Hospital, Institution or
WCity, Town or Village Jo h ns b J Y,- i Street Address Ad;roncia:c IC. T; - Al t,"il n 4i4111e.
W Manner of Death®Natural Cause Accident ®Homicide n Suicide ❑Undetermined ending
Circumstances Investigation
W Medical Certifier Name Title
G 1�- mo.s v-1 oy••r z rb KPA.
Address
112 Sh;10 d.I S old N_rI('1-+r\ r,r-e11_1h-1 N y t2 85
Death Certificate Filed I District Number Register Number
City, Town or Village , )chnSbV,t 1•Sco•57 5 I I
El Burial Date Cemetery or Crematory
El Entombment 01 ) Z) / z-bllc) 2_ine_ Uicu.) Cs(ernex--G ry
Address
ACremation CN:A ,a\h eY' cZ, d C^J e y\:`1oc AI
Date dace Removed
Removal . and/or Held
4 and/or Address
N Hold
0 Date Point of
aQ Transportation Shipment
5 by Common Destination
Carrier
L LiDisinterment Date Cemetery Address
Reinterment Date f Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Bcx y-\er F-,)n t'v- i Htyn e 0 11 3 0
Address
I .Oxxe S.-1- • n)Qeev�sbis,r\I( N�� 17-go Li
Name of Funeral Fir Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
CC
it
;'" Permission is hereby granted to dispose of the hums emains de rib above indicated
Date Issued 1/0.,///(;p Registrar of Vital Statistic e
(signature)
District Number 5655 Place s Q f l n 5 b vt cINN l a-6 q 3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Z l)/ iii,t0ez,-,Date of Disposition 71 nh4, Place of Disposition r
2 (address)
CO
= (section) h relat number) (grave number)
0
g ��f Sim
p Name of Sexton or Person in Charge of Pre ises
�' /1� please print)
Signature (.✓L Title G"ll&litible
(over)
DOH-1555 (02/2004)