Strader, Nancy NEW YORK STATE DEPARTMENT OF HEALTH r o70—)
Vital Records Section Burial - Transit Permit
Name First Middle .___ Last Sex
�► 'II I - . c ' I a
',. Date of Death I Age If Veteran of U.S. Armed Forces,
i 2_0 I War or Dates
Place of,Death Hospital, Institution or
4 City, Town or Village ' n a t o,j-\ Street Address I II 1\4e.r U )i v\ j jr-
rn
Manner of Death N Natural Cause ElAccident 0 Homicide ❑Suicide Undetermined ri Pending
41: Circumstances Investigation
4.
tv. Medical Certifier • Name Title
•5 •►, A ' II
ti Address
rii Death Certificate Filed f District Number Register Number
r„ City, ow,n)or Village I rl d 1 CU L 0 5 3 ,
3 Date El Burial
or Crematof v
Burial .3 ) 9 1 I, )Ye- \`! t u 1.a' oLt --c r`y
Addr
®Cremation La---L i'LJh(,t n, NV
Date ace Removed
'�
'�o Removal and/or Held
and/or I Address
r, Hold
6 i
1 Date I Point of
`. O Transportation I Shipment
,i-+ by Common Destination
Carrier
0 Disinterment
Date I Cemetery Address
Date Cemetery Address
:: 0 Reinterment
. Permit Issued to ' Registration Number
> Name of Funeral Home '`'�,p'Z't a 1 ;_ C c
f Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
a�
m
li Permission is hereby granted to dispose of the human m Date Issued \?J1< ins
descri e hove as indicated.
1�3 , Registrar of Vital Statistics Lc/Lr• � eL.[ /Y'
y*E. nature
3 Place d rl u-f [flel'ict✓N �el �._
.� District Number�� �
I certify that the remains of the decedent identified above re disposed of i ccordance with this permit on:
" Date of Disposition ?"d 3'/S Place of Disposition i x, / ✓ -).(,4 4(
(address)
•
•. ,• (section} ,Q (Iqt num r) (grave number)
• Name of Sexton or rs r of Premises oL ' (flu rY
A./�.. (please print) ( Al Signatur - Title .
DOH-1555 (10/89) p. 1 of 2 VS-61