Loading...
Riley, Grace NEW YORK STATE DEPARTMENT OF HEALTH i Vital Records Section 4 Burial - Transit Permit <' Name First Middle Last Se C�2Ac e LL E ) CZ.-1 L✓L. Date of Death©` i �� 15 Age 5 1 If Veteran of U.S. Armed Forces, J ; War or Dates Place of Death f Hospital, Institution or �, 5 ���� �cs k 1 • City, Town or Village G e"5 FG1\3 ! Street Address Manner of Death R Natural Cause Accident ijHomicide O Suicide ri Undetermined El Pending Circumstances Investigation Medical Certifier Name--r-. (�(� Title CI 11h0 -- \UC0.(\-6 CGr°.'‘Pl i Address U i:i 5 a km l r .,ve,3 FcV\s .K`'1 I.D. 5D i Death Certificate Filed District Number Register Number i, City, Town or Village (\e ^5 C-74".S S i,O I / 7 Date cemetery or Crematory ❑Burial 01 1 a ( c�0 V_S 1� v i t_, Lfe w.a'\o' ®Cremation Address& 04. G r Q.-oG S 4v`c e. s A Date `ii Place Removed g❑Removal 1 and/or Held ,.• and/or Address it Hold O Date Point of N❑Transportation j Shipment Es by Common Destination Carrier 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address { e Permit Issued to ,� l ' Registration Number ,' Name of Funeral Home/airarC� �` �Qker Fc�w et0-1 /Dome' ; ci ) ' CD 4 gi l Address // La{ €,-- C of. , ( u ecr)Sbu.n j , 'UQ.w tiv-k igAY/ Oii I Name of Funeral Firm Making Disposition or to Whom F. Remains are Shipped, If Other than Above 44 it Address UI .ilk; `=l.iW Permission is hereby granted to dispose of the human remains described above as indicated. • Ilie Date Issued t 1 I. 2 1 5 Registrar of Vital Statistics L 3 C .A4-v\,2_ lL (signature) 01 _> : District Number 560 I Place 6lenj �4//Si /a z :.; / � I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i, E Date of Disposition I/13J i 'tr(Place of Disposition ti-' 2 (address) Ig C (section) /(Iot number) < (grave number) CName of Sexton or Person in Char of Premises ro, L. s- ei z (please print) / W Signature i r Title v4ID (over) DOH-1555 (9/98)