Lee, Juliet ,� k # sz?
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Nam First Middle Last Sex
\u II et 1--i �.e— Pe 1/Y10 l .
Date of Death Age If Veteran of U.S. Armed Forces,
-- ! 1- ZO J (P 0 War or Dates itf p
1- Place • Death ff -- Hospital, Institution or
W City;.Tow or Village ( h / La <. Street Address !t Fa . a f r-DUrlpj
C Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined Pending
W Circumstances Investigation
lit Medical Certifier Name Title
�i Let_ N. ] .
Address
(; lotkfrsville iNy .
Deat - ificate Filed ` �- ,, Distric Numb r Register Number
Cit , Tow or Village tip r c l_L t� os4 Li
❑Burial Datei
J 1 -s�emetery.or Crematory
::ID Entombment 2a1)S 41 n e Vl e-l4J fka
A.L�s
Cremation L(Qt,n h
Date J . NY Place Removed
Z Removal and/or Held
2❑and/or Address
H Hold
0 Date Point of
0"0 Transportation Shipment
0 by Common Destination
•
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to le
Registration Number
Name of Funeral Home M l I. 'r ( " -yM 0 I/gc,
Address L L Q A /zf21-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
WA
Permission is hereby granted to dispose of the human r ains descri above s -ndi ated.
Date Issued 24) --lc Registrar of Vital Statistics
signat e)
Nil District Number Place.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 7/itI(c- Place of Disposition -W•U-.,i ( c__
(address)
til
fia
CC (section) ,(lot number, (grave number)
Name of Sexton or Person in C rge of Premises l.)
Z (p/6►ase print)
iLi
Signature Title
(over)
DOH-1555 (02/2004)