Breger, Dee NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Buria - Transit Permit
Name First Middle Last Sex
Dee 5 r ee r,.,..�.i.e_
Date of D �i!r Age r-� If Veteran of U.S. Armed Forces,
3 - - i l '-1 3 / 3 _War.or Dates /U
f!" Place of Death i� G f(`. Hospital, Institution or d r
ZCity, Town or Village Street Address k,
Manner of Death RI Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Ili Medical Certifier Nape Title 5u.V\ 1h- SCANu 6if&tA kJr = Q
ec. Adder()ciru,i , ut
4,..„.9
/tip
Death Certificate Filed District"Num-her Register Number
City, Town or Village V-� 1 e(y C4 0, LI 7 g 1 7
❑Burial Date '— /2 ` r 6 Cemetery or C m ry i j , r J 6._
l r (/ 1
❑Entombment Address _ /�r f C�� j
pCremation 2/ UlGt,Q` QeS. `9 ( L }-1 bc,, /t/y
Date Place Removed
❑• Removal and/or Held
P.
and/or Address
l= Hold
O Date Point of
EL i—i
Transportation Shipment
Q by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to 4, ,,� Re istration Numb r
Name of Funeral Home (0/►1 6 c c't r� t`�`y`� g 0J.3 CL
Address
Li0 ? nAe )ite_ a\/e. _tzr.,,,f1:656t, 57i, _ /Up
Name of Funeral Firm Making Disp sition or to Whom / ~7e/^c
Remains are Shipped, If Other than Above GG ��jj
• Address
ir
LEI
AL
Permission is hereby granted to dispose of the human rem i s descri,. - . above a�SLy�
s indicated./
Date Issued\ ,11( O/t,Registrar of Vital Statistics ( _ ` ',t i L.
`-t..
�1 nn -� (signature)
District Number qs-, Place rt �V O F rl�!"-.J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k. �,f
Date of Disposition i(it[(b Place of Disposition /fitu,U)twJ ( ncv}oic_
(address)
Lu
0
LC (section) (lot numbe (grave number)
a
12 Name of Sexton or Person in Charge of Premises /A L ti lf-
I(please print)
• Signature Title
er t 1 "
Title
(over)
DOH-1555 (02/2004)