Clouser, Pearl 1/ /I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
1..o•_s 5 e. (t
Date of Death Age If Veteran of U.S. Armed Forces,
i
U ( d-1- 1,2�1 t- 9 7 War or Dates
I•- Place of Death Hospital, Institution or
W City, Town or Village SA(Z W-r c . SOU-'65 Street Address SA_-A'ToG A �6S C i t A L.
Manner of Death LG Natural Cause E Accident 0 Homicide ❑Suicide E Undetermined 0 Pending
ELICircumstances Investigation
w Medical Certifier Name Title qn D
o Oz" A, L r�AgAbo� V '�(
Address
t( Ca‘...) ��\ S i. S.(\0 Alb,6 h Scz k r.)S N`t l 1di:dz.
Death Certificate File DistrictNumber Register m
7 mb jo.e
ber
City, Town or VillagetN bi
1,1❑Burial Date C metery or Crematory
•
❑Entombment Address
,Cremation Q ., Ak..i.: g. Z Q....�- c iNSc Q-`1 A) i i2U0L4
Date Place Removed
Z Removal and/or Held
A ❑and/or Address
H Hold
Ul
Date Point of
❑Transportation Shipment
3 by Common Destination
loi Carrier
El Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
ti Name of Funeral Home D� 1-45.4^o Q i s 'AL,r,-)i= 24.4- 1-.1)•M l:'- O L L Fj
Address
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
W
w
C Permission is h reb granted to dispose of the human remainydes 'b aboaf licated.
Date Issued i Q; 1t Registrar of Vital Statistics `—� (signature)
)
District Number Li j b' Place .5 p:cib 3014,1_4,...5
NI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition i A1/4 Place of Disposition -- tfj.4 Vo,.., Cj{tc ctonV
2 (address)
W
U)
a (section) ff4(lot number) r (grave number)
p Name of Sexton or Person in Charge of Premises A',tot_ 3"4
(ple',tot_
4 Signaturety t.— Title at'll ZbpL
(over)
DOH-1555 (02/2004)