VanOrden, Anne ifr
NEW YORK STATF,,,UFPARTMENT OF HEALTH 'S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
e n>c c\ Van Dc-6e N F
Date of Death Age If Veteran of U.S. Armed Forces, -124 1 i 1 Z01S 1-2- j War or Dates n] l r�
,i Place of Death I Hospital, Institution or
• li C• ity,I or Village conS10ur-1 Street Address 3c/3/c, I ee t g..ir AY/zlia(/
• .�c�l.. Manner of Death®'Natural Cause 0 Accident 0 Homicide ❑Suicide Undetermined ❑Pending
i Circumstances Investigation
M• edical Certifier Name Title
Atj
O LNI non M . e-; 1 /6 e2n ,nn PIAS;Ci a n
Address
14 I-0 \ f cx y f•pcxc\ (l.k_oo'S\ovv' , Ny 12-goL)
' <] Death ertificate Filed i District Number Register Number
fa Cit , Towor Village ( Y1S\ Y 5(.0 5 7 l�
Date • i Cemetery or Crematory
❑Burial \2I 1� I IS ; P,n e v l C v3 C.r,e rno,}i Y
Address A 1
®Cremation C r-k\I-Q.N � ( o, S)9\_W. 1. I .1�-�U
Date Place Removed
❑Removal and/or Held
and/or Address
c Hold
0 Date i Point of .
It Transportation. j Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to _ _ Ave.- Registration Number
s ;9 Name of Funeral Home 'NK�}2 -�,�61-1.;3-4 A p//39_
Address / c
/l L 0-� L�7Z.-- J 061,7ri.5 IS v 12-e f i 2 4/ .
Name of Funeral F Making Disposition or to Whom f
Remains are Shipped, If Other than Above
r(
4 Address
• w
11
Permission is hereby granted to dispose of the human remains described above as indicated.
;<; Date Issued \'I.?- I C Registrar of Vital Statistics ___e , 146A. 'mac c
isi (signature)
District Number n.P 5 I Place Q U c L n S b V r'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- /�
WD• ate of Disposition 13 _, /- j Place of Disposition i' pe v;ec,J CfPmQ or:v kv)
2 (address)
11.1
Cl)
C (section) (lot number) (grave number)
O Name of Sexton or Person-in Charge,�f Premises tJ1,.�,lo .Ofune6e
g / (please print
W Signature �,c'►, 46 Title ['rem,ctpr
(over)
DOH-1555 (9/98)