Monroe, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Wst Sex
& V cc_y,.J �P)91 oft, c PLr"iaz r
Date of Death / Age If Veteran of U.S. Armed Foyces,
//o h.0 f( 6 yv�S or /�-Dates .4/
}• jTown
e of Death / Hospital, nstitution o
or Village C16-�1 /` VLS e AddressWnner of Death❑Natural Cause 0 Accident Homicide 0 Suicide Undetermined ri❑Pending
Circumstances Investigation
la Medical Certifier Name Title
0
Address
D h Certificate Filed �- District N ����rer Reg r er
City, own or Village CLd�,J J /-0?�L S �`
❑Burial Date Cemetery or rematory�
❑Entombment /l /// , ' �tr 1/&�
Address Al®.Cremation & U /(. iEO161D G U6`2.,ws a 0, v
Date Place Removed /'
Z❑Removal and/or Held
1 and/or Address
HHold
to
0 Date Point of
Transportation Shipment
E. by Common Destination
Carrier
rk ❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home t"f Gy na.(d ,. L CC Rincr 0_1 .)(YVt. 0 ) 1 L C
iiiii Address i, L0.kyQ -HQ SA. , Q�C.enSbutv , N1Cv...3 Jor ,2s,?C`-\
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
Address
IX
t
Permission is hereby ranted to dispose of the human remains de Oil
ab�e as ted.
Date Issued I/ Z!�// Registrar �of Vital Statistics ;
(signature)
District Number 3 i/ Place o��,A2 7%' /,,y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
til Date of Disposition LI-127 t k Place of Disposition Pm/V h.) Cci,r c tort v rn.
2 (address)
Ui}i
f
CC (section) a (lot numb (grave number)
Name of Sexton or Person in Charge f Premises r•s��N'( "'°^'it
iiit L (please print)
Signature T Title C li,t M kj(?if.
(over)
DOH-1555 (02/2004)