Whittemore, Sharon NEW YORK STATE DEPARTMENT OF HEALTH 4i 535
Vital Records Section Burial - Transit Permit
Name First Middle Last Six
:> S �'vi/ S Gdi 9.-/6 t-Or»
<; Dade of Death/0/26/..
Age�,�- • Ifweteranar or��U.S.Armed Forces,
Place of Death Hospital, Institution or
• City,Town or Village ��i� M9�c S Street Address (yX A& i( 4jp/r-076_
.. Manner of DeathQNatual Cause Q Accident p Homicide ❑Suicide ❑Undetermined El Pending` -'
Circumstances Investigation
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Medical Certifier , Name Title
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cQ ,evego s,- - Ciati /
Death Certificate Filed District Number` / 1 Regis'�Vu9ber
>:;; City,Town or Village E-A6 /79L e S
Onto • Date /c.7/L, 2e /r) ortfrt �',Q 1'1 7 atzt.
. 0 E nt
I Add / ___4 46<_ re2 f_Aliu lc Ai/ 1
S Date Place Removed
--A rn Removal
and/or Held
E Li Iiii armor Address
Fold
Date Point of
[]Transportation Shipment
by Common Destination
Carrier .
Disirrter<nernt Date Cemetery Address
a Li52
❑ Date Cemetery Address
Reinterment
Registration Number
Permit Issued to - �c--
Name of Funeral Home ,Q,Q.�i 11!// 4/JC__ i goZS
<{1 Address/l 4)/ € , /IJ y lv��d
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above --.__--
_; Address
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Permission is hereby granted to dispose of the human remains dosed
:» Date Issued /O/9�Zv!Z Registrar of Vital Statistics , _� _
(signature)
District Number . ? 0/ Place 6/ 6i_l I
I _
« '. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'fi
;a', Date of Disposition io lb I(Z Place of Disposition .get Oil v C u r 1 -
' (address)
(section)n) / as )c1f
� )Name of Sexton or P in Charge Premises r,,
(
9 signature
r- Title `OWt60
(over)
DOH-1555(02/2004)