Clarke, Rae f Ilk
NEW YORK STATE DEPARTMENT OF H •EALTH • A z I,
Vital Records Section Burial - Transit Permit
Name First Middle E Last 1 Sex
tiii 1:20.e._ , CAoy-A4 c F
m Date of Death 1 Age I If Veteran of U.S. Armed Forces,
03- 1,-\-7... 11.Q. 1 g 1 I War or Dates I\) \ A
.....:,
i-- : Place c_ff.plieqi--th I Hospital, Institution or
I
Cityr Village (:).-0ee-CQ0Orj 1 Street Address -7Q-. kr\d'‘ConcA. RVE
Manner of Death Alc7 Natural Cause E Accident 0 Homicide J Suicide ri Undetermined ri Pending
' Circumstances "4 Investigation
,... Medical Certifier Name Title
i,g§§ 'MAY i C CA. Aucy NeAd,1 (p,i3si c-ti
Address
Cat/-ey f--60,:ck , (DoeencbDrs , ith/ 17_2\01
% DeatQatik-i- mate Filed".‘ II trtcrber 'Re .41e,lumber
a. CitkTown j•Village L.I\I eensbo r 1 1- )
Date I Cemetery or Crematory 1 .
E Burial 03 t2...‘ I 3.01 Le ---P l e.. V,ev1/4.) C y-.91,a.1-oye I
Address _
::::: EX Cremation OUCCYNS)Ouri , 01
_.
Date Place Removed
2 —Removal .
and/or Held
and/or Address
a..... Hold
(4 .
0 Date . Point of ..
al E Transportation.I Shipment
5 by Common Destination .
.--,. Carrier
Disinterment
Date Cemetery Address
Date i Cemetery Address
::: Reinterment
-
Permit Issued to I Registration Number
i
vi Name of Funeral Home . . ---R Al1:t.,--K-„4"--7:,.';i5.71,;9-.F.-, :‘,.,;-- 1 C_Di,LSO
ig Address i ,--, ,..-.
if 1-4,1•Fig-yt,i I 6-, .‘ 7,-. . (9 i-W----AiL Ci 0 il....61 . A
Name of Funeral Firm Making Disposition or to Whom 6,/ ' .,/ -
Remains are Shipped, If Other than Above
7-• Address
i ea
; .
N? Permission is hereby granted to dispose of the huma remains described a otve as indicated.
M. Date Issued 1 02 c7lOj Leegistrar of Vital Statistics
r,..( igriature)
District Numben—LO fl Place
ai
::....i:i I certify that the remains of the decedent identified above were disposed of in aCcordanc: this permit on:
1...i!
5 Date of Disposition 3/it fit Place of Disposition .g.i Or-, Csfre41011%"-
2 (address)
1.1.1 ..
u)
m (section) A4iot number) r_. (grave number) -
0 Name of Sexton or Person-in Charge of Premises . ,„1,ri,.
z 4 - ..A.44 (please print)
:
tli Signature Title /4 m Mk
.,..
- (over)
DOH-1555 (9/98)