Pixley, Crystal NEW YORK STATE DEPARTMENT OF HEALTH n 11IS-
Vital Records Section Burial - Transit Permit
Name First- �� Middle` Last � S
�', �( e-A,a,Le_
Date of Deep Age If Veteran of U.S. Armed Force —
'., �o i k S 7 War or Dates
}_, Place • e-.h / Hospital, Institution or
1.21 Ci Town o VI age C �n p' S
Street Address 13 7 -4-4PVC Pa A.
M.- , •eath N Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined C Pending
Circumstances Investigation
LL! Medical Certifier Nam p t�,� Title /l
At
Addrest Care_ L-,.1e_ ' S�r�. j
S q r 1 aak(
Death -- '..te Filed district Number _ f Register Number
City Town o illage (/ a 5 3 _
_ Date / Cemetery or Cremat y /
Burial �! All �4o4t ,.�cV; ) L/'c......- :
Address
" Cremation i.. GA$b" , A), Yr
Date cp / Place Removed
Z " Removal and/or Held
`—'and/or Address
v) Hold
0 Date Point of
0 Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home S.tio'c cr-, H.- 1 j,c _ !so 9't a
Address
7 er-,uv. AV �:
� ....) A) '�a�
1 ► ..
Name of Funeral Firm Making Disposition or to Whom
"" Remains are Shipped, If Other than Above
Address
iii
Permission is hereby granted to dispose of the human r ains scribed ov s ' icated.
Date Issued 9/a 3/ri Registrar of Vital Statistics
a re) t�
District Number cc 3 Place r 1./2 / /tje_w /a r✓ .-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ifiniii Place of Disposition PioUi J �r f o:ti•-..
(address)
W
N
CC (section) ,(lot number) r""' (grave number)
Name of Sexton or Perso in Charge of Premises 4 0-A14C �c»+gt}
ZItik_ (please print)
UJ Signature Title (Ili:PO1
DOH-1555 (10/89) p. 1 of 2 VS-61