Roach, Shirley NEW YORK STATE DEPARTMENT OF HEALTH # (°) 1
Vital Records Section Burial - Transit Permit
Name First Addle Last Sex
2 Ley- A.t )9-�h1- Fd-I//9Z19
>:>� Ae Date of Death g eteran of U.S. Armed Force ,
' 2- Z I-S 9 a War or Dates
J.i Place ath ' tion or
W City, To Village �t) � Q Street Addres /113,V c. s ,Z,
0 Manner of Death'Natural Cause O Ac - ent O Homicide O Suicide O Undetermined Pending
ILI
Circumstances Investigation
W Medical Certifier Name (� Title
C J i)2 V iJAJ c. 4N-7Q )
Address
Death -r- icate Filed / t ber / R is r Number
City own • Village (n ' Ict� U -1t3
OBurial Date Cemetery or Crernato 3
['Entombment �'/-3 /3--7 Jn) f 11 J la,�, )
Address n ,� ^
'Cremation 06-7C 6h /mow 6 L 6T't1,512y-
c/VZ7
Date ' Place Removed /
❑Removal and/or Held
and/or Address
F Hold
t11
O Date Point of
aw O Transportation Shipment
O by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home µ{xy ck , er -er FL ti.N,xa,t �1 b b 1 t a
Address f
11 I-z-4G.ttetFc S+rfth Quncc b r , N, `J.Y k._. 1' O
Name of Funeral Finn Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Ir
Ui
Permission is hereby granted to dispose of the human mains described afxr as indicated.
Date Issued 1 c)-.t 1 Registrar of Vital Statistics c-, 01. n,A_�
(signature)
District Number `� Place I O(,. {-., �� �q..- �
I certify that the remains of the decedent identified above were disposed of in a ordann e with this permit on:
Date of Disposition 2/ei f)'s Place of Disposition guiti..,/2
(air.",4,—
ss)
re (section) //(lot number) (grave number)
pName of Sexton or Person in Charg of Premises / t ,Sew
(plbese print)
Signature X. - Title ��c�1
(over)
DOH-1555 (02/2004)