Mitchell, Shirley NEW YORK STATE DEPARTMENT OF HEALTOI II �37 Vital Records Section Burial - Transit Permit
Name First Middle t Sex.
S ►2 L. /ILg1� /G/TCkJ-i L Fe-t nti
Date of Death �f A If Veteran of U.S.Armed Force,
z /2,�i/J— War or Dates Ai!10'
"�' Mannerw ath /�, Hoe tetutton or
C ,T r or Village V( c� -x fS v t Addr l ��f u12a�t��/ �2. ��-�) ��
Manner of Death Natural Cause [��ent Homicide 0 Suicide ❑Undetermined J Pending
Circumstances Investigation
Medical Certifier Name Title
TO ld\,-) TT-0 u'76 g vvcx., 1-l�
Address _
/d 2 Pr-wi,t. '
, Ct „_, Fi,,1 )2e-6f
Death cate Filed�-,• Di N R t r Number
City,( oWI J*Village Q� ,6 C` "`-'
El
Date r� Cemetery c(r Cr ato V
E l:Burial / S erfi �ry�"'y) /6(''J
Address
remation v bc,.J� a U1r1-y /U C"
Date Place Removed '
Z 1-1 Removal and/or Held
and/or Address
Hold
0p Date Point of
to[]Transportation _ Shi• ant
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home HC/nard b` rker Funeral Home_ � Of l 30
Address
l/ La a-tidte t. , bjs ,- ,/J LIvrk- /agoy
1,1 Name of Funeral Firm Making Disposition or to Whom
mm: Remains are Shipped, If Other than Above
-,s Address
Permission is hereby granted to dispose of the human "ns described abb vas indicated.
v Date issued. a4L- Registrar of Vital Statistics Q, ki-�
(sig •ture)
1b��-� O >} District NumberSGS '1 Place S�L-'7'--'
I certify that the remains of the decedent identified above were disposed of in accaanceyth this permit on:
5 Date of Disposition 3/31 f/T Place of Disposition 4?LtL C '_.
2 (address)
W
g (section) ot-number ` (grave number)
GName of Sexton or Person in Charge of Premises14,ii, 3:440-
z (please print)
Signature Title 1 """iM f
(over)
DOH-1555 (9/98)