Bearor, Anne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
„.7
Name First Middle Last Sex
19 Ai AYE- 172- 63 (2 /-• -2-)7)9g
mi Date of Au.%,, . If Veteran of U.S. Armed Forces,
War or Dates We
Place o Death Hospital, Institution or
Zi 'City dr or Village FTL--04€1,49 A'D Street Address 041:-#(.6a.s104 oVaRs Ili 6 Gr
ti
ci Manner of Death ONatural Cause 0 Accident 0 Homicide u Suicide El Undetermined n Pending
In Circumstances l'—'Investigation
La Medical Certifier Ngme . Title
6vAiiii/P Rai6
Address
. .;?7 cE3636fiDe ).4y, ic o A? 7-- -d 3 te1/9 ic,ii; A1)/.. ./..26../.,
li!!ii De7rQgstificate Filed District Number .5.7 65 Registnber
in City own r Village g 7: EI)CeigRO
Daurial Date
7— 1..2-- ,,.?a o I a Cemetery or Crerygp
P//ifEi •
e0c2Z-977197-0 R/con
0Entombment Add less
II NrCremation 40 C/b---b.-w s-,ee./g,t , ,y i.ocpez
Date ' Place Removed
Z El Removal and/or Held
and/or Address
t: Hold
Q.)
O Date Point of
85 Ei Transportation Shipment
0 by Common Destination
Ri! Carrier
Date Cemetery Address
Disinterment
Date Cemetery Address
• 0 Reinterment
Permit Issued to Registration Nteber
Name of Funeral Home/27/9204/ Faxiaiwz hzeri-ie 0///7
Address
62e, eE30)< o?77 Co eTwAkv /v/ /.. c16...2 7
.) ..
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr.
113
P7. Permission is hereby granted to dispose of the hum n ins described ove a indicated.
Date Issued 7///OGY6Registrar of Vital Statistics
.
(signature)
C
District Number 5955 Place 7-61a)4(6 74' iC4A74-spGIM-leiOi MY
•,:,n I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 71 1 i in, Place of Disposition -13%‘,e0 . auttoriv—
(address)
Ui
CA
Ce (section) i- (lot number) (grave number)
0
tti Name of Sexton or Person in Charge of Premises „S las i re-04-
(pl se print)
14 Zi- /43 cetikliv,
ci Signature Title
(over)
DOH-1555 (02/2004)