Baby Girl B NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Na First Middle Last Sex
a�1 (11 I C B eema I e_
Date of Death Age If Veteran of U.S. Armed Forces,
101 t 9 (2 o j Dates
)rr. P ce of Death C Hospil0 lnstitutio r
Z Cit Town or Village I' ►1 Street Address r
a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
Actidress NY
eath Certificate File Distri t Number Register Number
City Town or Village fa-{byk Cc1'n'nc�Q) -9-cj0 1 - 3
urial Date Ce tery or Crematory
['Entombment I /7 5 ( 2 6 l l 1 f\P U 1-2 e, r r eA----e
Addres
❑Cremation )-0 er‘FmbufH t tit'\ �
Date Place Removed
9❑Removal and/or Held
and/or Address
H Hold
i
0 Date Point of
ti❑Transportation Shipment
d: by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to �- Registration Number
Name of Funeral Home ec�� 3 �y E-Une I m 3( l-I-L.13
Af-dress n JJ l /
j Q U 0 -t( YN O aoA Ca)-Q P_t'� `j u,n4 t i"`I' 17JSYD174
Name of Funeral Firm Making Disposition or to Whom
14: Remains are Shipped, If Other than Above
Address
Cr
in
fl Permission is hereby granted to dispose of the human rema es ri d abrc 9e indicat
Date Issued lb\7 ( 12 ( Registrar of Vital Statistics {{
(signature)
District Number`_c ) Place A,0.'-t0.__ r' JS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
.1 Date of Disposition 1 0/25/1 1 Place of Disposition Pine View Cemetery
1 (address)
COErie 4 7 C 1
CC (section) (lot number) (grave number)
Ct Name of Sexton or Person in Charge of Premises Michael Genier
(please print)
Signature
q\ Rf9INAAA1%.RSuperintendent
Title
(over)
DOH-1555 (02/2004)