Sawyer, Sue NEW YORK STATE DEPARTMENT OF HEALV+F. # Z
Vital Records Section Burial - Transit Permit
Name First��� ��� Middle Last
�E� Se
Date of Death A e If Veteran of U.S. Armed Forces,
- I - Zv( ( 7U War or Dates A
Place of Death Hospital, Institute r
it Town or Village (607 S Street Address ems S &jprrL__
`Manner of Death
Natural Cause El Accident El Homicide 0 Suicide riUndetermined ri Pending
L? Circumstances Investigation
ill Medical Certifier Name Title
rl r
�2- K'ha -a_
Address
i f3U rCt✓2 ,6&//t Lia. N-11
iii Death Certificate Filed In District Numbers b Register Number
City, Town or Village
'::::::i❑Burial Date Cemeteryu; ,_, ///5/20/I fir:4 ' pr Cre atory
1repiCee-iiia,e-444A AA QEntombment Address Cremation .Z/ 2u1 kol. &leeIGS j z./ i\f/. 1o)co 4-
, Date Place Removed
Removal and/or Held
and/or Address
i= Hold
to
0 Date Point of
in Li Transportation Shipment
2: by Common Destination
Ei Carrier
•
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home e.T,vi C it a o rzLQ i4r YK2 O!4 6 `t—
Address , ,l �J
05 (... .11A oaf e & ti 'Y
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
I
EI
"` Permission is hereby granted to dispose of the human remains describe 4447
bove as i icat
Date Issued Registrar of Vital Statistics �� /`
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IL. Date of Disposition JAN ill ZO Place of Disposition wt 0 a ir,,/ 1...rein-d o r rt.\.
(address)
LU
to
cc (section) 4 Ole'
(lot n 'er) (grave number)
Ct Name of Sexton or rson in Charg of Premises �is�
2.,. (please sprint)
Si gnature k Title CO2 i+tY�(61t.
(over)
•
DOH-1555 (02/2004)