Secor, Sheila NEW YORK STATE DEPARTMENT OF HEALTH it //
Vital Records Section Burial - Transit Permit
Name First /� Middle Last Sex
-Q l / i' r/- (0-I " /- /v7 a
Date of Deat Age If Veteran of U.S. Armed Forces,
o 3 / / /3 ‘e,
War or Dates
l Pace of eath / Hospital, Institution ` � r-/—r
(C yJ;Town or Village / j 5-,/✓` !if Street Address ( ���/c(r/A,`
f�/ ��(;1 /-�a'-M nner of Death Unrmined��tural Cause �9�ccident �Homicide �Suicide � �Pending
i Circumstances Investigation
W Medical Certifier Nam Title 7
�
" Address
G,� i ,s% tf-% s- A-4// ' /.)-*/
De.th Certificate Filed District Number ' Re ister Num er
9 r�
Town or Village v�` // Q / /6<k-S
✓Burial
Date f Cemete or Cre a o --L, ;7/),_,?/, Ar 1;;. /2-e K/Pel-c2(A-(17--7er/ f/ J--;-7
['Entombment Address VI
remation (�--t°2�!?./ i / /1 . /, ,
Date Place Removed
Z �Removal and/or Held
and/or Address
Hold
to
O Date Point of
050 Transportation Shipment
La by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
IN Permit Issued to Registration Number
Name of Funeral Hon aGT4y/ l7 f 7 J/ AC 0--e,/ly
Address c-
>" ,_(-7-- Ckr---7/_e -// 7,eriT, < 7-- /2(P/ * ..
Name df �Gneral Firm Making Disposition or to Whom
114 Remains are Shipped, If Other than Above
• Address
it
Ifs
f' Permission is hereby granted to dispose of the human re ains described above a indicated.
Date Issued / '7 Registrar of Vital Statistics 'i„1%'a,f , y(/
/j177111e/
(signature)
District Number �/ Places � 4-� i
I certify that the remains of the decedent identifi d aboArvere disposed of in accord a with this permit on:
tit• Date of Disposition 3 j h JI S Place of Disposition "1'ac U''� C am...
(address)
LEE
CO
1C (section) /li _,(lot number) (grave number)
ci Name of Sexton or Perso in Charge of Premises 14. Sc„
1z (please print)
:*: Signature u C Title ( l?f '�
. (over)
DOH-1555 (02/2004)