Chant, Donna NEW YORK STATE DEPARTMENT OF HEALTH E If ii 22
Vital Records Section - - Burial - Transit Permit
p Name First Middle Last Sex 1
-Do-c\'c•o`. �v o.‘AI 1 F
= <: Date of Death I I Age i If Veteran of U.S. Armed Forces.
w` . p3 Z3 ZO\ - `-1 j War or Dates K),A
Place of Death Hospital. Institution or
City a ,or Village V oyeLk v Street Address \\\ "WI', ;rc v E. 1eS"
Manner of Deathi ,,Ltill Natural Cause ❑Accident E Homicide fl Suicide ❑Undetermined ri Q Pending
:'. Circumstances Investigation
': Medical Certifier Name Title
Ev c ? i 1)erne v- M
Address
\b0 Pa-el-, Spree- i &lens Fa)1ss J%J' 1 Z8o
Deat - ificate Filed I District Number - 1 Register Number
. •Cit •r Village M 'Q V 1 V- - ' i-
Date I I Cemetery or Crematory
Burial j O�j 1 Z1-} f L.o 1 `-p iie \ i et),- G-'e�.,o. c-
Address
U.I Cremation/ nocev,s'2�Y N \-2Jbo'4 ,,
._ Date y i dace Removed
CRemoval ! ; and,or Held
and/or 1 Address
i Hold ;
7 ' Date Point of
Transportation.3 : Shipment
a by Common j Destination -
Carrier
Disinterment Date I Cemetery Address
Reinterment t Date I Cemetery Address
s -
Permit Issued to I Registration Number
- _ Name of Funeral Home_ l-'-i::: ._�cl I :y 1 -%i f 30
Address jj: :_, /,_- t V I `l_
Name of Funeral Firm Making Disposition or to Whom .! I I -
Remains are Shipped. If Other than Above `'j
Address
I
'_ Permission is hereby granted to dispose of the human remains described above as indicated.
{{ Date Issued 3/?W / It, Registrar of Vital Statistics i 3 /0 _ .-- ---
l l >`_ (signature)
District Number VS(o oZ Place U r'� Q f / t'.�e Ci-l�-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition 3)7$00(6 Place of Disposition 4 US., ci s.
(address)
U)
C (section) tot number) (grave number)
0 Name of Sexton or Person-in Charge of Premises jzr�, Sj''
(please print)
ZSignature A Title i iii'1t2R
(over)
DOH-1555 (9198)