Byer, Edith NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death / Age If Veteran of S. Armed Forces,
/ i i , ,j 6 $ 7 War or Dat
}- e of Death Hospital, Institution or
iTiab own or Village A - Street Address AIL M zA
.ilk V anner of Death f�Natural Cau ❑Accident ❑Homicide El Suicide ❑Un termined ❑Pending
�-F� Ci umstances Investigation
W Medical Certifier Name 1 Title
fl Ga cAc.1 D5jOM-e_ M I ,-
Addre s
M G.
`f Ne-,- cc-,.-w4,,A 4vc ALbA.. /i I aatav
Death Certificate Filed District Number U j Register Number
own or Village AL L k.,y. (0 I
■Burial Date Cemetery or Cremato
❑Entombment Addre6 /4' /a of 6 in c it e+.•, Cc^^,t4-61
s f( vQ
[gCremation iv.e_ens b-r API'
Date (J' Place Removed
Z El Removal and/or Held
2 and/or
� Address
to Hold
O Date Point of
«30 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Hom Gn 5/vor c- -•.n c rot..( /4. w. 4-4-• CS 0 `4'7`3
Address
7 I erm Ave 6 r. N I 1G) gx ,
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
2 Address
f
IU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued la 4(.0 Registrar of Vital Statistics -li. K.n'Ic ,._-
1 (signature)
Ei District Number !01 Place 'A Lb k^ l Ne t-3 r Vr
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lif Date of Disposition ,(Nit, Place of Disposition P&AL arc...„
(address)
U)
IC (section) (lot number (grave number)
Name of Sexton or Person in Charge of Premises t
2 ( ease print)
W. Signature t- • Title
(over)
DOH-1555 (02/2004)