Donely, Brenda - # 03
NEW YORK STATE DEPARTMENT OF HEALTH ;
Vital Records Section Burial - Transit Permit
Name First Middle Last Se
13 re/J8.a. ° &Ale ly �I7 A
Date of Death j n/Age If Veteran of U.S. Armed Forces,
06 — v10p- 9//6 War or Dates it.t d
Place ath _ / Hospital, Institution or
Cit Tov or Village S r DO/til _Street Address .l6 �( 4311 Tea-- WAS _
Manner of Death a atural Cause El Accident 0 Homicide 0 Suicide ri UndeterminedPending
Ul Circumstances Investigation
j l Medical Certifier Name f Title
m rr / f rin�,w pi
_0
Address
Deat " .cate Filed District Number Register Number
City, Town r Village �G i 1r d U A) / i 3 v'
iig[ Burial Date / Cem ry or CrematêJ-e 'A
y
❑Entombment' C��o 1 p" ���F r/Ve a colt) 7 —
Address
pAremation Cc)r)P 0. S b Uv A.)
Date Place R moved
Z Removal and/or Held
❑and/or
Address
LI 1
Hold
0 Date Point of
1 Transportation Shipment
Cs by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
iiiki Permit Issued to �j Registration Number
Name of Funeral Home �COlD- S A. Kli • -6/1)er / /(0zl - Co S 17
Address r 31 ,�-4 , (TO13 i P IQ-._- t / L 7O
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
s Address
t
Permission is hereby ranted to dispose of the human re 'ns described above as indicated.
Date Issued Registrar of Vital Statistics U ru D
signature)
District Number 5�3 Place j v a-en_ /..-‘ P46.____
_____,S
'`'' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lit Date of Disposition )I I IA, Place of Disposition -t it i /r fo
2 (a dress)
ill
to (section) (Jot number) (grave number)
Name of Sexton or Person in Charge of Premises G it "' _S1"gl
-
/�� (please print)
Signature G.1` Title � `'� -
(over)
I
DOH-1555 (02/2004)