Reed, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ril Name First Middle Last Sex
}-i.e.\en h , 2eed i 1-
Date of Death • •)_ f Age ( If Veteran of U.S. Armed Forces,
iti � �� � �S (�1 -1 Z War or Dates N ) 1-
Place of Death f Hospital, Institution or
'iG
ARV) Town or Village - ile c \ I Street Address i s_ \ feY i T-4 '
,„, M• anner of Death Z Natural Cause 0 Accident .---'Homicide 0 Suicide n Undetermined P'-nding
Circumstances Investigation
Medical Certifier Name Title
ft ' i.r,(L. CA mm;nshc3 m D
Address 1 ro lvs, e ia,,;1 �rcc.c-F l C 6,--Los_ Fa Ik s 1 r'1�/
Death Certificate Filed i District N mber i Register Number'
City, Town or Village 5 6 n ! I A 9
I
Date I Cemete or Crematory
__Burial 1Z O`Z— / 2015 'Vole v1e1d rrnma
i Ad ess y
2 Cremation! S\0, r Ni\ Z OL
-
Date l Place Removed
2 C Removal ! and/or !—!Lich
-- and/or --- —= — --
1..; f Address
Hold
i
p ! Date Pint of
N ^ Transportation i Shipment
L� by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ' Registration Number
s Name of Funeral Home Bcz'er I-une(cj/ /1omz I
•
/ / /- _/r , l jam' G t 3 L
MI Address /1 Lai-a c.- tc • , la'L{(Lio iD4-L LJ 1 AIGW t0ck I CJO
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
A• ddress
N
<. Permission is hereby granted to dispose of the human remains described above as indicated.
IM Date Issued 12J 2 12_0I i Registrar of Vital Statistics LA.)mil_L -t..R 1j-APB
(signature)
•
D• istrict Number SO 1 Place 6 CQ.v\S Vo 1 ) S , Ai-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ii D• ate of Disposition Ih13I1S Place of Disposition Zdi ,
ej OP?-w
f1 (address)
ll
01
CC (section) / (lot numb r) (grave number)
Name of Sexton or Person in Charge of PremisesGi t4r,i 3itierO-
Z (please print)
Signature /2 IAA— Title (vo►}yPL
(over)
DOH-1555 (9/98)