Cummins, Valerie T
NEW YORK STATE DEPARTMENT OF HEALTH p
6��
Vital Records Section a Burial - Transit Permit
Name r
t Middle L�t S
�a 0 'e (Li ,ir) i77_S />wJ�
iiiii Date of Death Age� If Veteran of U.S, Armed Forces,
q`� G War or Dates
>.' ' Place of Death �I Hospital, Institution pr
City, Town or Village ( .car( ritA
Manner of Death
Street Address ���r��� .ram
::. 0 Natural Cause Ej Accident El Homicide El Suicide 0 Undetermined ri Pending
Circumstances Investigation
im Medical Certifier Name Title
4 m4(/ 7)oLI1P MD
Addre s.
.:,.:: i 3S Alprtli Z4 Lk): i 4-&r, AI /
iiiiiiiii! Death Certificate Filed / ' District Nu b r Register Nu ber
`' City, Town or Village 0 4/ -a4—)0 /6 3 /
Date - eetery or Cremat ry
❑Burial _ (�y�Z,G-L� /4 r tneV'trw r re 4il'c
:... Cremation `
Date / Place Removed
0❑Removal and/or Held
and/or Address
g- Hold
Date Point of
gQ Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
>' Permit Issued to Registration Number
II Name of Funeral Home h sn J 1'- r,„e.T.L I 1-1Me .�--____ 0 O 1
: <> Address
«ii Name of Funeral Firm Making Disposition or to Wh m
'" Remains are Shipped, If Other than Above
Address
W
1
':> Permission ss hgrebv granted to dispose of the hum emain desc be o e as indicated.
iiii<' Date Issued �1J2 • -i4 Registrar of Vital Statisti s
nature)
.ffi: District Number ))3 Place C.)(/(A it
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
5 Date of Disposition Ili* Place of Disposition Alit,../ (is vn4#((U. .
S (address)
ISJ
2 re (section) fl(lot number) (grave number)
Name of Sexton or Person in Charge of Premises C<n ,S1,nr/f
Z 1- (please print)
t Signature (4i( Title CAC Mllr t
DOH-1555 (10/89) p. 1 of 2 VS-61