Petty, Joan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section _ Burial - Transit Permit
Nam First Middle Last Six
Date eath(:)fi?
AgePe
If Veteran of U.S./
.S. rmed Forces,
q " ?/' o/ ) 75 War or Dates
f-- Place of_Death A Hospital, Institution or
City;TownIor Villag�'4 +t.[LL,a..� 6.. Street Address 7.C/.f � A �(
• Manner of Death®Natural Cause ❑Accident ❑Homicide El Suicide Un termined ri❑Pending
Circumstances Investigation
iii Medical Certifier SS Name ,_)(r)Titt
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Death Certificate Filed District Number Regisctt r Number
City Tow�or Village>t .c C� O 6,3
D
! `❑Burial Date Ceor CrCg matory n
❑Entombment Cll�Co///
U C e..-t-ti `}1 p ,nLid-c,ud._,
Address �J
]Cremation -R./yam b LtA
-4.Date Pce Re)rri/o1J
gEl Removal and/or Held
and/or Address
IZ: Hold
Date Point of
i1D Transportation Shipment
d by Common Destination
Carrier
El Disinterment Date • Cemetery Address
iiiit❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ll.Prt ,L_Qa t- 0// /q
imi Address 035 7 >8 0 ,ait.plkiLit '- L'a ke )1-11 W'84/c)-
go Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;, Address
i
c. Permission is hereby granted to dispose of the human re ains escribed abo as indica d.
. --.27
Date Issued '- 02L',_ if Registrar of Vital Statistics , ,
(signature)
District Number,Qa53 Place .7c01 L' i)la.--/<-9..
`.;_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition 1111111 Place of Disposition PtMIL.) Ce"-Cit oryv►—
(address)
iti
411
iM (section) (lot umber) (grave number)
Name of Sexton or Per in Charge Premises Ac•1‘
,_ .n�ia-
J + (pl se print)
Signature qp� Title CRI�+np��olL
• Y (over)
DOH-1555 (02/2004)