Dunn, Eline V
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section' Burial _ Transit Permit
><` Name First Middle Last . I Sex
Date of Death I Age I If Veteran of U.S. Armed Forces.
0/'-6.3 --gyp/av (Z1 j War or Dates
Place of Death I Hospital, institution or
2 ORO,i own or Village G\£Y1S TrxAS 1 Street Address LO3 i3v- Sk-r€e
Manner of Death ix Natural Cause El Accident El Homicide Q Suicide ri D Undetermined Q Pending
DI Circumstances Investigation'
Medical Certifier Name Title
Gke kNak Y\
Address -
\\ -2.\ &,re `( 06,6 �r�s\ov�r , 12. /
D th Certificate Filed I District Numb - I Re ester N&nber
City.Town or Village C-Ur V0A\7 I 360/ I.
Date 1 Cerery or Care atory
Burial 0, 0 12:0\U ! nt �ftety C ct aA-ov V
Address ( - J '1'" i
At Cremation \U-V- \wC \ st) ,I c
Date _ Place Removed T'
r2 —Removal f and/or Held
—and/or ! Address
Hold
—tO
Date _ t Point of
Transportation, Shipment
5 by Common Destination - - -
Carrier
.= —
Disinterment Date ! Cemetery Address
>:-
Reinterment Date ; Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home 1 T---•-� f •
Address
it L t>r i} i L- 11 i✓ .�. t i}vcL r-S i5 i Z
0 ..d A'', V f 2 4 c- Li
Name of Funeral Fim Making Disposition or to Whom j
Remains are Shipped. If Other than Above `�
Address -
F . Permission is hereby pranted to dispose of the human remains des ibe a ve icated.
Date Issued G'i�i��120/b Registrar of Vital Statistics �� � r/ ..,4;
} ` (signature)
' District Number 5 °� Place •• G/1.t., ,'/� /i> 12001
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
tit Date of Disposition I-6-14 Place of Disposition 1'TI C. v eu� Cr2rr/ o 7
2 (address)
LU
Cd!
i (section) \ (lot number) (grave number) -
0 Name of Sexton or erson-in Charge of Premises • J t1 `1 n 6C he..
(please print)
144 Signature � Title C• A44,110-/
- (over)
DOH-1555 (9/98)