Boyd, Adele NEW YORK STATE DEPARTMENT OF HEALTH'S I
# 100
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Apei �
Date of Deatthh Age If Veteran of U.S. AArrmid"Forces, -Tern R
ll Q, 3) a-th 1 q 0 War or Dates N 0
• Place of Death �+ Hospital, Institution or tt'�__
5 City, tillage- l9'LE:t tS -LL S Street Address (.,-u=t S -FALLS T1�S P{Th L
Ci Manner of Death gNatural Cause El Accident 0 Homicide El Suicide 0 Undetermined ri Pending
ili Circumstances Investigation
tgi Medical Certifier Name Title
ClN N 1-cE R - -ircib K 1Y )
Address
14 `1V\NnR_ 57R\v F, ) Ciu EEN S 6 c{ -1r, !a E'O
: Death Certificate Filed District umber ' ( egister Number
City,Tewn of-Village- G-cE t\l S 41.1,C 5 6�) 313
Ai 0 Burial Date :reyFiCrematory ,
❑Entombment -rise.s ' 1-
Address a Di
ELL) C ry ,nti._,
ss Cremation (A � q (,(AkF:R RS?,, u EEE 1 Eau( , 1\ 1 a?'0'4-
Date Placer. Removed
gEl Removal and/or Held
it 1- 1 and/oldor
H Address
ta
0 Date Point of
ti❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration nNufn er
Name of Funeral Home ikc o - A
&De L 4� m E) I,N C hrt
Address
sCI D -1(Y\0IOT A Lr^ S j L- € GE o P`G-€ - 1 1 g�{-s'
Name of Funeral Firm Making Disposition or to'-Whom
• Remains are Shipped, If Other than Above
;;, Address
IX
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued v2 -- 7- // Registrar of Vital Statistics Leo-.4,.,Q,.
signature)
ig District Number 5 01 Place U.N`S co, ,, S , fu y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
iti Date of Disposition f-fa 7/oil Place of Disposition RMA$h,, b itmcfot,u,..
(address)
Ili
t
CC (section) (lot numper) (grave number)
D• Name of Sexton or P son in Charge Premises r�S�P�If 's�0
(please print)
EI Signature L Title CYIhE,i TO i
(over)
DOH-1555 (02/2004)