Bosford, Jennifer NEW YORK STATE DEPARTMENT OF HEALTH , /L2
Vital Records Section Burial - Transit Permit
`•. ' Name First Middle Last Sex
�n(1ie-� ‘r rAy) In �ps-Curc1 F
Date of Death I Age I If Veteran of U.S. Armed Forces,
O)- 125)201 l.o 1 3 7 j War or Dates iN1 I A
14 Place of Death i Hospital, Institution or LoA-�
City ow r Village M 0 r e 0.3 ) Street Address I�10 o ebi �8 IA 4
p Manner of Death❑Natural Cause 0 Accident Q Homicide Suicide Undetermined ix Pending
f Circumstances 'investigation_
Medical Certifier Name Title
0 f`(\iC.nae\ SY- r .‘ Co- Mi)
Address
(-Weeny mi?d.,CAA (o"\ec e.._ i Alban•
' Ny
ii Death Certificate Filed District N�ye} Register flu ber
>> �
City own •r Village M( (e. � 9 5�i C/
❑
Date Cemetery or Crematory
Burial ' 631
0 1 I a.0 1 LD P,ne U e
1 .,J �'rQmcx -- y
Address -
Cremation
ZZ i Date _ y Place Removed
❑Removal f and/or Held
and/or I Address
Q. Hold
>
0 ' Date _ i Point of
N0 Transportation , Shipment
a by Common Destination - •
Carrier
Disinterment Date ! Cemetery Address
n Reinterment Date Cemetery Address
<'` Permit Issued to I Registration Number
1
Name of Funeral Home_ _ J/?X�Z�t_ �.J6}1s . .t lief I 0/130
Address
/
�l N Name of Funeral Fym Making Disposition or to Whom ,-_, ' •
w Remains are Shipped, If Other than Above `
Address
• ill
1L
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/, /` ( Registrar of Vital Statistics M
(signature)
District Number y c(o Place 4 J/1 Q F 7ke X Qf�,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
W Date of Disposition 3/3//L Place of Disposition giiVA,) C'f„�„c*on, .
2 (address)
LLi .
N
IS (section) (lot numker) (grave number)
0 Name of Sexton or Person-in Charge of Premises • haert,. Jr+ er
z
�/ (please print)
fit! Signature (,2 Title lib
- (over)
DOH-1555 (9/98)