Minor, Elaine /c-1V-hi
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section , ._� Burial - Transit Permit
Name First Middle Last Sex
E a, n tAo 1-Vv\o,r r
Date of Death Age If Veteran of U.S. Armed Forces,
1 Z I o I iS L9 g _ War or Dates N ) Pj
Place of Death Hospital, Institution or
Cit-, Town or Village )e_�5 Fc-0Vs Street Address Glens Fa 11 S 1
C anner of Death W Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
fa Circumstances Investigation
41 Medical Certifier Name Title
Address
CC, Par\4 Sk. CD.Ie\S _\\S, p i V 1
piii Death Certificate Filed District Number Register Number
En City,Town or Village 5'o/ �7
❑Burial Date Cemetery or Crematory
z 107 I 2-013 elf--;r\D- V.i e_ Cnosna+cr)
iiiiiiiiiii['Entombment Address
IN®Cremation 4 r151AN N 12_8-),
Date / ' Place moved
••❑Removal . and/or Held
and/or Address
f=` Hold
O.
Date Point of
❑Transportation Shipment •
rit by Common Destination
Carrier
❑Disinterment Date Cemetery Address
piaEl Reinterment Date Cemetery Address
Permit Issued to Registration Number
<: Name of Funeral Home B0,1.,D,r c,-\,,,,„\ 11 \k 0)13 0
Address\\ vv��-e.' � S-- . G YlS>)v(y i i V 1 2-f 6Li •
Name of Funeral Firm Malting Disposition or to Whom /
Remains are Shipped, If Other than Above
2 Address
it
In
Ix
Permission is hereby granted to dispose of the human remains de ribed a ve icated.
Date Issued /O2-�) Zp/5—Registrar of Vital Statistics
/ (signature)
«> District Number ,5 0/ Place '/ Al /tVy /L Ol
>s: I certify that the remains of the decedent identified above were disposed fin accordance with this permit on:
ill Date of Disposition f2 I g f is Place of Disposition 44 1...1 inri .._
(address)
Uk
0
ir (section) illo(.number)) (grave number)
CI Name of Sexton or Person in Cha a of Premises //ii SN++vr4(
Z. (pi ase print)
Signature (f� Title VQ
(over)
DOH-1555 (02/2004)