Mitchell, Donna NEW YORK STATE DEPARTMENT OF HEALTH 4 *A. "' c�
Vital Records Section Burial - Transit Permi
iim Name First _diddle Last Sex
DO c\r-a J 0.,)0- N;-1-che1.1 i F
Date of Death Age If Veteran of U.S. Armed Forces.
1 Z I (9 j zo►S LI42 War or Dates
Pl Death i Hospital, Institution or
�iace, Townof or Village G\e ��� I Street Address G) ens �V s �6t
iManner of Death Natural Cause Accident Homicide Suicide Undetermined Pendii1g
Circumstances Investigation
Medical Certifier Name Title ;ie �
�1 d Cu fl n� ru�►r ty �'J
Address /�
3 1 mno\oiz[, Co v GlS2vkS RA\5 ,lam\I 12-801
Death Certificate Filed L) District Number , Register Number
' &
;::;;: Town or Village e,r) 1\S �lvQ/ .5 7S"
Date • Cemetery or Cremat
ory
El Burial \ Z '01 15 I I J n e C farm a Vo Y`-/
Address
IN Cremation s,nSbof• 1 N li ) 0 (Tg Date / Placeemoved
fl❑Removal and/or Held
and/or Address
lgi Hold
Q Date j Point of
•
N 0 Transportation. 1 Shipment
a by Common Destination • -
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<] Permit Issued to _ ;� _ Registration Number
; Name of Funeral Home - _ JN<&>1.. i;,, Yi##-_. NC- 0113Q
iii Address
// / -�-�z� S; UV u�2.os 6 U i2 , /2 y
Name of Funeral F Making Disposition or to Whom
Remains are Shipped, If Other than Above l
Address
•
Permission is hereby ranted to dispose of the human remains descri d above as in 1 ed.
Date Issued /e O2 20/C Registrar of Vital Statistics
s // (signature)
:111.1
_ District Number S6C/ Place ae.. / //; .�Y /2$'O)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f;
WDate of Disposition 11--1-'S Place of Disposition ?,"ne v,'e L., (re,,,„',e ri",I rvt
2 (address)
i;,:I -
N
C (section) (lot number) (grave number)
2 Name of Sexton or Person-in Charge of Premises t m04 . &,,„.die
(please print!
W SignatureT_—,c,,, ��,,' ' Title Crern440r7 /4S51
- (over)
DOH-1555 (9/98)