Liddle, Marion NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle �a Sex
(n AR'So►� jSi 'N�'N is Li'�D L.is F
Date of Dea Age ` If Veteran of U.S. Armed Forces.
SI2t 1 a01.S 9 b War or Dates
Place of Death Hospital, Institution or
City, Town or Village cZAi- V %L-L e- Street Address "r1-•`O% AI` K‘V R.
13 Manner of Death�Natural Cause ❑Accident Homicide Suicide Q Undetermined ❑Pending
fL Circumstances Investigation
Medical Certifier Name..., Title
1,
Address
I Register Number
> < Death Certificate Filed L District N` �l�-��, e9
EN% City, Town or Village G—fl.• ILL G
Date / f Cemetery or C ematory
is ❑Burial b /O / �-O « tJ E 1 t \'i WI 14 j�-t_''1
Address y�
:: Cremation �v AK-�?- D 0•_.1C .,NS t'.v,?__ti 1'IS 04
Date I Place Removed
fl❑Removal I and/or Held
and/or Address
g Hold
Q Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
iiffi Permit Issued to � Renistration Number
Name of Funeral Home v ., ., . . Rive L FJ,J .�'t il-t_ ANC" 9,�L*)
iiiii Address f / ...,
// (- t J I lam- J i 0+.) .aC 6. Oily Aiy, 12 if
F' / Name of Funeral Fi Making Disposition or to Whom
Remains are Shipped, If Other than Above
AP Address
iS
i
Permission is hereby granted to dispose of the human remains • •'• - o - as indicated.
in
:�:� f!0 Date Issued /ZJ 5 Registrar of Vital Statistics . 'SWI •s
(signature)/�
Mi District Number �- Place Vt'U& et- cV luilk ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
>i-
w Date of Disposition lP/4 fis- Place of Disposition
2 (address)
1u
U)
CC `(section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises •
z (please print)
Signature Title
- (over)
DOH-1555 (9/98)