Morehouse, Ernestine NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
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Name First idle /A , Last Sex
e rZA)or i-/4v- i7 Olt►d" / 76►t_rS mU:S 1i" ! ryin e
_ Date of Death A e If Veteran of U.S. Armed Force .
2- �� /�' ; 7 War or Dates i/ 61
of Death � Hospital. Institution or
.fCity, own or Village l 1 te,., s Feu,s 1 Street Address 7 / 1n.1 cr {S
annex of DeathRNatural Cause E Accident C Homicide E Suicide n Undetermined Pending
Circumstances Investigation
0.lij Medical Certifier Name ,(� Title
1/d'ed SS el- btia-ko,A.... /1
Address r
C kh4.-- �' iLro 7 GA U C -A
D th Certificate Filed J District Number Regis r umber
'111(Cit own or Village G Lcf S / I Cod / 6 ,
Date 1 Cemeter r Qrematory
Burial S— L/ /S' r. Pi*."-)S t_iS
IAddress_
Cremation lW v r,...)s Q U
Date PI c'e Remov
2 —"Removal f and/or Held
—and/or ; Address
0
Hold
0 Date Point of
Nr Transportation Shipment
fl by Common Destination
Carrier
Disinterment
Date I Cemetery Address
Reinterment 1 Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home ' �-�-- ; .,_);;�-�Y-. - fi j j 1 3O
Address / r 1
/1 (� )- /J- lam) t 2:`._ . 6>u`&L).S u 01 - j f f y_ /`l,-C:
Name of Funeral F)( Making Disposition or to Whom {;/ 1
ii Remains are Shipped. If Other than Above
Address
8
>. Permission is hereby granted to dispose of the human remains described above aindicat d.
' ' Date Issued 5/L)) 15 Registrar of Vital Statistics LA3CA.A 1,
(signature)
District Number-ZOV Place , ' ..5 .7//.5, 1/y /)W/
I certify that the remains f the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 341(1 I Place of Disposition Pine_ '5 4 C ?AC ^l` /`l
if-
(address) J
Ul C-- 2t 5
cc (s on) � (I t number) (grave number)
0 Name of Sexton or son in Charge of Premises Ct . t • ' �j
Z e--- (please print) y,
1 t
44 Signature - Title / Gp a.,
/ _ (over)
DOH-1555 (9/98)