Shaw, Freda NEW YORK STATE DEPARTMENT OF HEALTH , -1 1 1 J G ZLi
Vital Records Section - Burial - rans t Permit
Name First 1 (I Middle O Last Sex
id-ciow
{' Date of Deathp
/ / I Age iIf Veteran of U.S. Armed Forces,El J}:>; e I 7 9 jj// i N or Dates
PI e of Death • ospital, stitution
Ci own or Village /� Pius Sress
42 Manner of DeattlgNatural Cause n Accident Q Homicide u Suicide Undetermined Pending
Medical Certifier Name Title A Circumstancesn Investigation
I ICJI t`rl 1` C1� r1�i P\'-) 1 C.1 atm
IAddress
Y::� I�\ Car Pi 4Z d ,J Q wl en ,L 1��, 4- gag
y
D--th Certificate Filed W District Number 0� j Register Number
iliOp own or Village E1(. c,J i I—13'LL,S i �-i 2 t
Date i Cemetery o Crematory
L. Burial cP Z // /1 Ai i/ li 6�-.)
Address
0 Cremation 0 yith<rv� Q a 0,,l,S>3 1v
Date 1 Plate Removed /
❑Removal : and/or Held
--- --. - --- --
l:; and/or Address
Hold
0 ! Date — -- - - :;int of
Nfl Transportation { Shipment
E by Common Destination —
Carrier
Disinterment ! Date Cemetery Address
:,? ❑Reinterment 3 Date Cemetery; Address
-. Permit Issued to [�p�Y.er I Registration Number
ki Name of Funeral Home Pius era\ �oM e - O\13 O
_ Address i --
1\ L.a C-ay�\S-e S\re e--)-- Q v.eensbikrj , NN(- 1 240L
::;;„ Name of Funeral Firm Making Disposition or to Whom
.=" Remains are Shipped, If Other than Above
E44 Address
!f
=<:: Permission is h reb granted to dispose of the human er ains described bove as incl. ated
in
tiiig Date Issued 0 �pj/1 Registrar of Vital Statistics
( ig ure)
>> District Number / Place
77
I certify that the remains of the decedent identified above were disposed of in accor ance w this permit on:
f
f Date of Disposition q/i 'j r Place of Disposition ZU& 6 6C
2 (address)
ELr (section) q (lot numbe (grave number)
G
Name of Sexton or Person in Charg of Premises /Ai( enb-
wt
Z (please print) /
Signature Title 117EOTA
(over)
DOH-1555 (9/98)