LaTulippe, Betty NEW YORK STATE DEPARTMENT OF HEALTH 4 ` \\ 4 II
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ete_A-4r1 A- Lc,i ua,??-e. r-
Date of Death Age If Veteran of U.S. Armed Forces,
�-e\C.� y a\--j , 2.0►a. .8 g War or Dates
1 Place of Death Hospital, Institution or
Z City, -c Town or Village I 12- —)c c Street Address Fc 1-1-‘,,ets c r A/�•4- ,1,1 l i,+'t-(
IIIManner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LLt Circumstances Investigation
Medical Certifier Name - Title
II T . , ;\' ( c,,,,,, Jr PIA.
Address
i3c'tY=-.ate.; ..I , R t. t&.),,,, ;�, NJ 1 J9 2-'
s< Death Certificate Filed _ District Number Registr Number
City, Town or Village kacc C- Zu;c.,r� SJ 75�3 /
❑Burial Date Qkmetery or Crematory
❑Entombment �VA a , O 1 ‘r\-t V�'e.. C�{'N-� A-Ci 1 V \
Address �7
DI Cremation \ C _uG I<e(- R , Os�-e-Qiks J �L c"l ( Y t 1 a ZS ULf
Date Place Removed
Z❑Removal and/or Held
2 and/or Address�;
Hold
tft
0 Date Point of
% Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Ili Permit Issued to _ Registration Number
Name of Funeral Home ��'zcs.Ar\ t l�e.f\ny tee;c,I 14-0 1"4 (.7 I I-11-i
Address
5-3 c .‘At,Kt c I?? ; .A- sfi ,ry , 'I , PV C'j
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
t
UI
't` Permission is her by ranted to dispose of the human ins described above ass dicated.
Date Issued ,I)-- Registrar of Vital Statists az
(signature)
District Numbe 3 S Place ;;-k a`&wc,r•e, A)1
1...:::i'k I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition ►'i-et 5 l tdiZ Place of Disposition ,�L r�..
(a dress)
lU
Ili (section) (lot nun76er) (grave number)
CI Name of Sexton or Pon in Charge o remises o t lfr
(please print)
ill Signature /4L. Title CF,EiYiK06
(over)
OH-1555 (02/2004)