Baby Girl A NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name st Middle Last Sex
birab t k I Rrnoie___
Date of Death Age If Veteran of U.S. Armed Forces,
l DI IRI-2-0 arorDates
H- .ce of Death ospital' Institution or
Town or Village (�1C (1 n Street Address �,. . ICA rota`_
a Manner of Death rNNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
111 Circumstances Investigation
W Medical Certifier Name Title
0 '<-P_t\`-1 A . e denbo rn , Cal k
Address
,. )1 i'n .ii---h-e_ -1t-°(--e_e--\- , ok.fiki=1_A04, Swrion INN
Death Certificate File District
orc j nL
S E I
>::14Burial Date _Qm eetery or rematory
Entombment 10 12 5 120 1 1 \ x n-e. t E w `('�
-e rn'ei-e
❑ A less �f
['Cremation Q_.e_e -��bUr� i N I
Date Place Removed
❑Removal and/or Held
and/or Address
F—'' Hold
l)
0. Date Point of
cn Li
Transportation Shipment
0 by Common Destination
Carrier
ID Disinterment Date Cemetery Address
Li Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home {1 3 r\n�1 Xeero' t i 'n-___ 0 i`'fLI 3
A dress
T Qt )n,\6-e,,r O&c axe-ein l W l grr01--I
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ir
ILI
LL
Permission is hereby granted to dispose of the human re ins s beda s indic d.
Date Issued/0 I Z 1 (70. I Registrar of Vital Statistics
(signature)
District Number Li 50 I Place_C1ra-.\—( S,P vASS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 1 0/25/1 1 Place of Disposition Pine View Cemeter
2 (address)
WtO Erie 47 C 1
IX (section) (lot number) (grave number)
aName of Sexton or Person in Charge of Premises Michael Genier
5 /j
�,� (please print)
Signature Title Superi ntendent
(over)
DOH-1555 (02/2004)