Byad, Dawn v * c
NEW YORK STATE DEPARTMENT'OF HEALTH
Vital Records Section Burial - Transit Permit
Name First1.3 Middle J. st Sex
-
Date of Death Age l n of U.S.Arr ted Force ,
(Z.-//(o If 4' 6O Dates ,i e
- of Death �; `Ho a nstitution
City own or Village L C,"..5 S t.-d-t,&S Stre Address t ,,,s /4i.t f
anner of Death Natural Cause 0 Accident cide Suicide �Undetermined Pending
- Circumstances Investigation
in Medical Certifier Name
A'V +t;i 1, I. !J
Address t�
Cib lIblin '. I Se—) ram, Ay I ..?7
th Certificate Filed District Register Number
\Ci own or Village L12 .vs F,A- 5(oa I l �'
❑Burial Date Cemetery o Cremato
r` �
Entombment / // /� ,1 l't
Address
iiiiiiiii.15kemation �( u H'14. 1 a U 6 ,„• d Uy A
Date Place Removed /
Removal ' and/or Held
and/or
Address
Hold
0 Date Point of
Transportation Shipment -
E by Common Destination
Carder
ailQ Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Dfr? &y• . FV,. 't.. i 1 0 //& a
Address
.11
3 I I (ie-- ��--7--br �'g- U ,ix a ( A. / Z P 0 c7
`` Name of Funeral Firm Mal Disposition or to Whom
Remains are Shipped, If Other than Above
E Address
Ir
111,
Permission is hereby g anted to dispose of the human remains describ d bo a in ' t .
ig Date Issued /al• / vblw Registrar of Vital Statistics
Igifil (signature)
District Number ��Q7 Place �eq A, `U f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
1.11 Date of Disposition IL ficii Place of Disposition 44142 l ily-.
2 (address) (
tii
IA
M - (section) ,(lot number) (grave number)
ci Name of Sexton or Person in Charge f Premises 6 ��. ('�1n�d�'
( ease print)
Signature Z/ 4mr Title (fl/tL
(over)
DOH-1555 (02/2004)