Bacon, Deborah NEW YORK STATE DEPARTMENT OF HEALTH d 1
Vital Records Section Burial - ransit Permit
Name First De. ___,/\ MiddlI-koiet,A e Last j Sex
foofa °icon F
Date of Death i Ag ( IfVetran of US. Armed Forces,
V /23/zO! V t!J`7 War or Dates
Place of Death Hospital, Institution j ( V Y.
6ity;- own-or Village C ‘ccoA,\I ,i'� Street Address ��u(a�� V r
Manner of Death on
k&j Natural Cause 0 Accident ❑ Homicide ❑ Suicide 0 Undetermined ri❑ Pending
UI
Circumstances Investigation
WMedical Certifier Name Sec�� �t ( In Title
_ > YI
Address to.Q ?C Yk sL @, c: /v 1 )/ IZc3 Q I
v Death Certificate Filed District Number Register Number
City, Town or Village 1T ,1 (/ j (I, 57 ?5 3
_„Li„0 Burial Date ( j 12 I i Cemetery or Crematory ka (? ,,�e \) tie l�) / �e(/y(u
rinV
,, ❑Entombment Addreslls/ f �o� ( f /� [� ) �j �lr(
pCremation 21 Quo leer �C� Quieeiis U�,m, �V f 1780`I
Date Place Removed
1,0 Removal and/or Held
and/or Address
Hold
g
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
If ..
Disinterment Date Cemetery Address
s „O Renterment Date Cemetery Address
Permit Issued to M
'iRegistration Number
Name of Funeral Home . • h ( iV11 ( V-U Y to ra/ \ oYvi-e b i 0 7 9
x Address
pz
rtcoo
JwcL� Fo(a C�
� wa✓rcf, )J`P IZ9LS
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W. Permission is her by gr nted to dispose of the human rem desc 'ir b• • • ove amindicated.
Date Issued p Registrar of Vital Statistics � �✓u -�-'`
(signature)
District ���1''r/
Number 57 J Place 1.(/dll�.
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (O'ak Place of Disposition eklOti.--/ Ahkek'—'
(address)
(section) of number) (grave number)
Name of Sexton or Person in Charge of P raises AS r 5
(ptese print)
,' Signature a Title ( eiheoit-
(over)
DOH-1555 (02/2004)