Crossman, Jean NEW YORK STATE DEPARTMENT OF HEALTH 4 r 4
Vital Records Section Burial - Transit Permit
Name FILO Viddie 1 Last 1 Se _ f'
Date of Death Age If Veteran of U. .Armed Forces,
r 1 G ` l' War or Dates
Hospitab
f+ City,Town or Village L �4 J % _ Street Addressutior or /c __
F Manner of Death N aural Cause 0 Accident fl Homicide 0 Suicide Q Undetermined _ Pendin
! CirGL[Mstances Investigation
Ka,-Medical Ce r f a. --4 -ride
`a _ /,fir:
&4.
G� A dress,
• Death Certificate Filed __ . �. District Number {:_ I Register Number
' City,Town or village., ,2,' ° , � _ ,
❑Burial 1 Date r .," _` Cetr} eery or Cr Bator f
❑Ent3ttabmpryt,---. t ",z''ii fictC'+ :e..w, t' C—?:-V.s'A. - -----
Add►ess
remation .'.
G c jWfc/ ' ! /
! Date ' Place Removed -_-.-_
C Removal 1 1 endror Held
and/or � Address
liki Hold i
Date Point of -
-115 L3 Transportation Shipment
La by Common Destination
Carrier
i
piairit ra�erit i Date Cemetery Address
u Reinterrnent Late Cemetery Address
Permit Issued to Registration Number
''a Name of Funeral Home 4,,/4",lie < /'c o *--tee - ,.... ! % ram '! -
Address _
// s1 :�9�1 ".('- -- _ r."de`;er.'.t' ivy .f.?ff
:.. Name of Funeral Firm Making Disposition or to Whom -
Remains are Shipped, If.Other than Above _- — -
Address
lid
' Permission is hereby granted to dispose of the hum pips described above as indicated.
' •i Date Issued «-,s/ / Registrar strar of Vita Statistics
(sgnaa re)
District Number I'4/1" u Place -1i fy
7
�%._. 1 rirlr fir' .i1 'r�'? .. _ _ _---
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3J/'IIl6 Place of Disposition _ -17.4(t_. L_ri"^ it.•-----------._------------------_
i
'tgi (section)' _ (tit n ereri /gra*n rn:be 1
Na racy of Sexton or Person ir, Gfrarg f Pternises_ ,.t f '"ni
e h °
- Signature Title _ _._- Lf" 'I-IM(..
(over)
DOH-1555 (02/20O4)