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Lanfear, Teresa
#b37 NEW YORK STATE DEPARTMENT OF HEALTH` Burial _ Transit Permit Vital Records Section Sex Name First I GIB ^ MMiddle��1 er\c C* Lastt L'o c cx r , fg Date of Death A If Veteran of U.S.Armed Forces, •� © .12.Q 2 01 ge a_l War or Dates Pt Place of Death Hospital, Institution or Street Address S�G.(1•a-�'r� Nuns,rX- -Rome- city, r Village Q�e erlSbi.�,�� _ � �Undetermined 1 Manner of Death Q Homicide Suicide ing 1131 Natural Cause Circumstances Investigation Medical Certifier Name Title N Pal-r e`r Address rrnc c tise)ntricre-Nuttber �SbcayDeath Certficate Filed Register Numbero+ City, owCr- or Village ( Qc S'ur•J '1 ' 6 • []Burial Date or Crematory 0 ' 31 ( v�b)j }�;�1Q f j 2°LJ l� C'tYla��O�1 Date Place Removed / r:Y Removal Z and/or Held " and/ Address , Hold 0 Date Point of Iti Q Transportation Shipment .ems by Common Destination Carrier 1 El Disinterment Date Cemetery Address El Reintennent Date Cemetery Address ilf Permit Issued to Registration Number Name of Funeral Home —eXaer Funeral ' rre_. Address t •1 t Laffkr.iie- S4- , CQ uee nsbu.ry , N e w..1 Yur k- i2 si o LA Name of Funeral Firm Making Disposition or to Whom i� Remains are Shipped, If Other than Above i�� Address '..iiii Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued g- 1-' .41 Registrar of Vital Statistics --e , eaz. ---fie Q Q (sign ) District Number 51 Place lA-e c n • LA,' I certify that the remains of the decedent identified above were di used of in accordance with this permit on: '"r Date of Disposition 9/316 Place of Disposition _ �f/+�t�/by, Cr"'��°f1lr K (adds) (sin) 1 (lot number) (grave number) Name of Sexton or Person in Charge of Premise thfs t 5tr r ateaffra Signature Title (over) DOH-1555 (02/2004)