Weber, Anita NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs // Middle `, , L st Sex
//7/ / `7 • Leif ��17-7'6%
Date of Death 1- - AgeIf Veteran of U.S. Armed Forces,
a&/ 7_,
- War or Dates
1. Place th/ �,I Hospital, Institution9+ ,--- • /0 �//
City Tow r Village NJ (% f Ack/ Street Address /Fj i i 07 �;K if t ( G9 .,,
141
0 Manner of Death '-Mural Cause ccident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
It �� �^ Circumstances2,.. Investigation
WMedical Certifier Name _
c� �O i -e / � Tle
.. /7
Address
,rin—"T/-i L 3 /--47 ,, A%--/x /..- aP /i.__
Death;C icate Filed // / Dis ricf t Number Register Number
City ow r Village \ 69/ Ili, I. s ,,, �� .
❑Burial Date f% Ceme ry or Crematory 1
�� ®�{— pia /-ee� ("2/17 e/ 6-/V
❑Entombment Address j
emation QJc-E�,l''��. . , ,( 7/ ,..y / ?
/-7
Date P',.ce Removed
❑Removal and/or Held
and/or
Address�;;,
In
Hold
O Date Point of
t
Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to � Registration Number
Name of Funeral Home 6 7v� ,. �
t /271,7�i :,7;-( �7e-
7 P,/,, “57. Cia,r- 7-e---77 c. '-Y /...2-P'z/.7
Name of Funeral Firm Making Disposition or to Whom
iiii Remains are Shipped, If Other than Above
• Address
Cr
ILI
iL
Permission is hereby granted to dispose of the human re ains described above a 'ndicated.
Date Issued ' " 6�jRegistrar of Vital Statistics r) G ,
7
(signature)
District Number 45 s Place—row-0 4 s c,t
1....:, ,,.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III• Date of Disposition 2 I411 i; Place of Disposition ,()€J 6er,r
2 (address)
la
at
cc (section) of number) , (grave number)
Name of Sexton or Perso in Ch ge of Premises Ari Soy-
2 (p/e se print)
• Si gnature Title .Si Pr9
(over)
DOH-1555 (02/2004)