Burnham, Ashley NEW YORK STATE DEPARTMENT OF HEALTH' ' ' 1
Vital Records Section Burial - Transit Pe mit
Name First Middle Last Sew
A5h14 Lynnurn � m t'
Date of Death Age If Veteran of U.S. Armed Forces,
3-5 . 0 0 War or Dates
P c of Death �---" Hospital, Institution or
City, own or Village 6 h .� s l-a 11 y Street Address (qi,a n s tu-//5 �r f�-
anner of Deathlatural Cause 0 Accident D Homicide 0 Suicide D Undetermined El Pending
Circumstances Investigation
Ne Medical CertifierLiiii Name Title
yu �rL ,f h el 2✓.& ,-c. v
Address
ffi
R `) g/2_,0.4-0 S.i/ C— t=, .1 s I- 6 . Al-¢t'
ath Certificate Filed/ District Number Register Number
iiiiiiiiiii Town or Village Co le 45 ii'ct-//S 5 Lo 0/
Date Cemetery or Crematory
❑Burial 3 - it - i ( pl..0 Q Y re w Ct e-,c,, /*ia..•--
Address
Cremation �U v n c ii.t,'') / - .
gDate Place Removed
Z❑Removal and/or Held
�- and/or Address
th
Hold
O Date Point of
pi Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ja Address
IX
fa
imi Permission is hereby granted to dispose of the human remains described above as indicated.
iiii Date Issued 3/9 l // Registrar of Vital Statistics IN
(signature)
13 District Number 560 ) Place �k S I �S i /v
) y
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
F 3- 0 tt
W Date of Disposition -'s:#8 Place of Disposition !At \J J C c(6r' 4_
2 (address)
W.
(section) 4N4T-1,,
ot numbe (grave number)
GName of Sexton or P rson in Charge f Premises Lh,,4G
z ( (please print)
LU Signature �'l� —r- Title Cl $ Mr c)I_
(over)
DOH-1555 (9/98)