Vannier, Emily y lb. ..
NEW YORK STATE DEPARTMENT OF HEALTH ft Slit
Vital Records Section Burial - Transit Permit
i Name First Em j L Middle '>��: ! ast Sex
•
:.•>: Date of Death Age ( If Veteran of U.S. Armed Forces,
11- - ' J ZZ J Zp 15 2 i War or Dates __
Place • Death I Hos•ita1...I titution or I
Ci Town a r Village.415 Q r bL �-- , treet Address U2 Ra E�r)to(� Ira_a_
Manner of Death Natural Cause D Accident 0 Homicide 0 Suicide do Undetermined ri Pending
ircumstances Investigation
sit Medical Certifier Name Title PR
CO c\ Conc.\ y
'r`' Address
2- ro c C��, r- Gls��s`Eo U S; j\- 1 1 a %0 l
Death cate Filed
} �l.l�QrI�IC t ; District Number Register Number
City ow r Village �'�- ( Z I
Date -�\-/_ \3 �` Cemetery r Crematory
:': ❑Burial Z 1 IN_ i V�
� �(
remation Address
.i ULIJU2 C iZ .) a te u�r�"
en b ;>v 12.%«L1
Date Place Removed
2 4c,Ela Removal and/or Heid
4
and/or -- --
Ei; Address
( Hold
0 Date Point of
NQ Transportation Shipment
ty by Common Destination
Carrier
Date i Cemetery Address
0 Disinterment
:::::. Reinterment Date ? Cemetery Address
Permit Issued to Registration Number
iii::' Name of Funeral Home 'Baker
ker fruneccz/ //ome 0 j ) �0
: <; Address
// Lama Lte to (3+, , ()(A t.,c.nslbtkrcd i JUe w I.. rK I Qe0.
; Name of Funeral Firm Making Disposition or to Whom
-- Remains are Shipped, If Other than Above
Address
>: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 - -taO 1 S Registrar of Vital Statistics -12 • )ZaZ. ---k kt
`< (signature)
' District Number Sip j 1 Place DV c c n S b J7 j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i-'
fDate of Disposition 7-a7- 15 Place of Disposition Rnc u:v.,,,, Cre•,,,Jacs'�
2 (address)
ILI
th
CC (section) (lot number) (grave number)
OName of Sexton or Person in Charge of Premises `y (k
/, (please prifat)
Signature Title 0%.ery,�Jvr 4554.
(over)
DOH-1555 (9/98)