Daniels, Rose 14 z11
NEW YORK STATE DEPARTiCIENI OF HEALTH
Vital Records Section Burial - Transit Permit
``' Name First Middle Last I Sex
Po - Down t-els
=>;�' Date of Death i Age 1 If Veteran of U.S. Armed Forces,
[AP i A i ibi to $t9. War or Dates m
.... Place of Death �w�n i Hospital, Institution or/�� ,!k��, �� i�q �
City,Town or Village Gi hits %I I� Street Address Rt 1 ew
>..:. Manner of Death 12 Natural Cause 0 Accident ❑Homicide ❑Suicide nUndetermined ri Pending
. Circumstances Investigation
Medical Certifier Name Title
t:3:`•
ii Address
3 1 W Q car 1- S1-ti-4-e• 4— &F, �1` 1 l2_' 0
Z Death Certificate Filed i District Numbe \ J ! Registe cke
5
Si City, Town or Village 1 � i
Date t � Cemetery or Crematory Pi�� ��W ������
El Burial Colo 1 I'a 1 2.0�1� _ u-
Address
. Cremation Cat-er,5bury --Mil
11� Date 1 Place Removed
2❑Removal and/or Held _^
.�• and/or t' Hold Address
17
ii Date = Point of
u)r—i1 i Transportation ; ( Shipment
a by Common Destination
Carrier
El Disinterment
Date i Cemetery Address
:;.< Reinterment Date Cemetery Address
Permit Issued to 1Registration Number
a Name of Funeral Home &titer / lct/ //ome_ i at i �(�
Address // LaFGc.t/ C • , 0t,1CLOS/ r , /U t/DrA- /aa'Ul
21 Name of Funeral Firm Making Disposition or to Whom
ES Remains are Shipped, If Other than Above
Address
f
i
ws Permission is hereby granted to dispose of the human remains described above as indicated.
l<`l Date Issued 0 i 3 1 L 6 Registrar of Vital Statistics CA- -A� v '.5
(signature)
ig District Number 5 rZ C( Place 6 ,,^-S \\S,
I certify that the remains of the decedent identified above were disposed of in (accordance with this permit on:
ti
5 Date of Disposition 6l IN lr, Place of Disposition 't iroat J �ef QMi-N
2 (address)
iLl
til
X. (section) / (lot number (grave number)
GName of Sexton or Person in Charge of Premises ( hekrn) lh^d'
F
(please print) ���
Signature 6 i. ,40
- Title
(over)
DOH-1555 (9/98)