Pedersen-Artale, Joan NEW YORK STATE DEPARTMENT OF HEALTFI ',- # 36
Vital Records Section Burial - Transit Permit
Name First ff.
iddle PidQJi2. -(LO'y � ( / l2eP%1ZDate of Death Age If Veteran of U.S. Armed Forces,
War or Dates
t-- Place o th Hospital, Institute o / ',
Z City own r Villa jLe Street Address ' IAA`-L
a Manner of Death Natural Cause Accident 0 Homicide El Suicide El Undetermined /. Pending
l Circumstances Investigation
la Medical Certifier a e Title a
Gl �` L`J
talyies p
ane A &P-,21-4ii LI) y 4..?s,2
Death Certificate Filed District Nu er ( Register Nuriber
City, Town or Villag 52
❑BUflal Date �) Cemetery or Crema /�Q��
['Entombment � �" � �r��""-"�.lu/
Address 6), ) U -�
L,Cremation
Date Pla iiemoved
Z ❑Removal an /or Held
and/or Address
t= Hold
0 Date Point of
05 Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Regis a n lmber
Name of Funeral Home `��� J121i_e1 ,
Address ( /0V 42E
VoName of F neral Firmd
n� 7spositi n or to Whom
��
Remains are Shipped, If Other than Above
„ Address
f>G
LAI
f't' Permission is he eby ranted to dispose of the huma e ins descri d abo 1 j,indicated.
Date Issue ` 0 %`j Registrar of Vital Statistics i- �(� ,h,10
(sign:ture)
District Number oa3-6, Place /1z/
Le 7.1 4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
t! Date of Disposition 5170 5 Place of Disposition .(7„4,L),. eti,}14,--
(address)
LEI
CC (section) I (lot number) (grave number)
DName of Sexton or Person in Charge of Premises Ar.tl ,S► -
Z (please print)
llta Signature 4 4—. Title (1r '"o° VZ,
(over)
DOH-1555 (02/2004)