Smith, Gloria NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section • Burial - Transit Permit
Name //First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
v -.75-/,6-- 7 War or Dates Ae-e)
Place of Death Hospital, Institution or ,� /
W City, Town or Village /Z -2115 jL wAt/ Street Address a1/�%-i!/L70/'/C vo,4-i'y
ilk Manner of Death Natural Cause El Accident ❑Homicide ❑Suicide El Undetermined Pending
tij Circumstances Investigation
iii Medical Certifier N me Title
Addres
4-2,-2.4..ei."--5 ,0 ,./ / 93 z
Death Certificate Filed District Number _ Register Number
Niii City,Town or Village �,'7/Z r--y ,/,A./ /5-5 p�
❑Burial Date Cem or Cre tory
['Entombment Addres i ' / � %�
>`>_ Cremation /r..-2 1-A. 1 c/ /
Date / ' lace Removed
C ❑Removal and/or Held
and/or Address
to
Hold
0 Date Point of
ti
❑Transportation Shipment
Cat by Common Destination
ffi Carrier
Eli
El Disinterment Date - Cemetery Address
•
❑Reinterment Date Cemetery Address
Permit Issued to \ / Registration Number
Name of Funeral Home ,,4/� J-)f5/ Avy//���z�L�i�: / 2/5//y
Address
9 S< ,1 , 4 - �S /ems i c_ Ay / -
Name bf Funeral Firm/Making Disposition or to Whom
1_ Remains are Shipped, If Other than Above
2 Address
t
.W
97 Permission is hereby granted to dispose of the human main describedbe above as indicated.
Date Issued %?7/5 Registrar of Vital Statistics( J f k'�i/`(,4
(signature)
District Number / s 0. Place u/) of �f 6/� buy]
I certify that the remainsr of the decedent identified above were disposed of in accordance with this permit on:
ILI !
Date of Disposition , 3/t/r,�' Place of Disposition �„�� cam....
2 (address)
Ili
CA
IX (section) / (lot number (grave number)
0 G 44 Name of Sexton or Person in Charge of Premises P ,,,,3,2hVil-
Z (pl ase print)
41Signature . Title itni01417iZ
(over)
•
DOH-1555 (02/2004)