Parker, Diana NEW YORK STATE DEPARTMENT OF HEALTH 7,S
Vital Records Section Burial - Transit Permit
Name First-t., ,�- Middle 1m Last Sex
../ Date of Death , Age If Veteran of U.S. Armed Forces,
II -23 - 70 ( � q War or Dates
j- Place of Death Hospital,Institu or /��
City own r Village t.j iS'��,u Street AddressrVL.`cL O� ccR Pt (LITt11°L
ci Man of Natural Cause ❑Accident El Homicide El Suicide El Undetermined ❑Pending
LEE Circumstances Investigation
ta Medical Certifier Nam Title
i pc COL-i 3 o iv P
m
Addres i I eb
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Death Certificate Filede- District Number Register Number
City, ,own • Village 9 14 eii gyow i3
❑Burial Date Ceri et ry or C[elnatory
p,24-�i j 0% /�� V i J � d t`/
` i El Er)Lombryient Address A
Iii remation 1 Qa �1-Va NV P-130 7
Date Place Removed
Removal and/or Held
and/or Address
it Hold
0 Date Point of
0 Li Transportation Shipment
Et by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to A.R. 1/ tiosi Registration Number
Name of Funeral Home A I1ILd4'� ✓417�A,�_ e- c2!o-79
,i. Address
2? 1A t/ cr--wr n , IU'/ cgs 2J
iiim Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
IL/
a` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /2-V 3 /,J Registrar of Vital Statistics
(signature)
iq District Number / .7 -y Place 01414. Or JGHaJS i G w,+✓
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t
LLI Date of Disposition (Z--28- S Place of Disposition P,ne tJ i cu) crnincjpty
a (address(
113
CC (section) (( number) (grave number)
Name of Sexton or erson in Charge of Premises ,) k-/'G-e4 (��-I t
z: (please print)
W.
Signature Title CA=/174k -
(over)
DOH-1555 (02/2004)