Lent, Ellen NEW YORK STATE DEPARTMENT OF HEALTH `` x ff 3SI
Vital Records Section Burial - Transit Permit
Name first Middle Last Sex
E l 1- Le,nt ie.mo .e
Date of Death A e If Veteran of U.S. Armed Forces,
i i - 2D('j `j War or Dates 1\ji7
i-- Place of Death ) ` Hospital, Institution or
City, own r Village � LUCZ-(2) -nk. Street Address ,M ) G
j. T
a to H c,Lf, R4
a Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide ❑Undeterm ned ❑Pending
W Circumstances Investigation
W Medical Certifier Nam Title
CI loll'&Q - .f qb
A ess i
bi i n
Death Certificate Filed District Number Register Number
City, own r Village LLu4 Lj,A Ze.r- 566(A
❑Burial Dat V. Ametery 9r Crema ry
❑Entombment US 13 ("5 1 1 ne v i e.Lc� ►incL�l�I��
Addreatr-, J
'®Cremation ULQ fSb t& I L I / •
Date J �`Pl ce Removed
Z Removal and/or Held
3 I—Iand/or
Address
{J
Hold
0 Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiisPermit Issued to Registration Number
Name of Funeral Home fin' Lt_?�,( f t iirj-CA + I Inc oo;' 1
Address
ail- C u,rct-) S-t, Lc JL Lt,(24..l--nQ I fig
Name of Funeral Firm Making Disposition or to Whom
Jori Remains are Shipped, If Other than Above
2 Address
M.
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fl Permission is hereby granted to dispose of the hum re ains des ibed a Ili,yes,s indicated.
Date Issued 5-/ 3- 1 Registrar of Vital Statistic �4 _ o -0N
(signature) `
District Number 6&5(.i) Place I n op La_ LtzEA-7
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
W. p Place of Disposition gtk
Date of Dis osition ti I�I�K' p ,",
aa6dd )
Ili
to
cc (section) (lot number) (grave number)
CI tt
Name of Sexton or Person in Charge of Premises
I(please print)
Signature 4 4- Title /Otto(
(over)
DOH-1555 (02/2004)