Peters, Eugenia NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section & __ Burial - Transit Permit
is Name First Middle Last Sex
Ev 6-,Eiv iA P6 02S F Au,�
Date of Death Age If Veteran of U.S. Armed Forces,
/Ed .22, .201/ 7 7 War or Dates WA
Place of Death Hospital, Institution or
itit3ibyc Town orc ge /.JA ig -jp wn! Street Address /Mgg. /y/5.:Dmalt eiCiViredt.
0 Manner of Death Natural Cause Accident Homicide E Suicide 7 Undetermined 7 Pending
tilCircumstances Investigation
W Medical Certifier Name Title
in D9c1/v 4 . "To/,4vsvk) AID,
Address
4 4 x / 1.)I(A t ern. S,o a)' « Al Zei S
Death Certificate Filed District Number Regi ter Number
;:( Gify, Town er-V+Ikge NARsozi sroweil /61.3
El Burial Date Cemetery or Crematory
❑Entombment ,EA . ,1 . 20/l P/Ng //11 ) CIL/�Ia /Z4'
Address
Cremation 61 ogedal�1[/n", ot/
Date Place Removed
❑and/or
Removal and/or Held
f,;; Address
th
Hold
0 Date Point of
0 Li Transportation Shipment
t by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Al. 4, Ce 41z1< ill/C.. . O/D 9'y
Address
-alb SA1Z.44V4/. ,Ouu L/J.�c,r� AA GM, A,y /a,/4/4
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,2 Address
In
Permission is hereby granted to dispose of the human remains described abov as indicated.
Date Issued -„„lc! -1/ Registrar of Vital Statistics
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District Number /613 Place Village of Saranac Lak
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iU Date of Disposition 3-i-it Place of Disposition -R r•c V1 e,,,) aY,nsu,� wi--
2 (address)
11l
w
ir (section) (lot nmeber) (grave number)
0
0 Name of Sexton or Person in Charg of Premises 1ir%aie v`r tom+
Z (please print)
Signature Title Cii'etbMIn MIA-
(over)
DOH-1555 (02/2004)