Jenks, Joan 2l
NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
Name Fiit Middle Last Sex
cat isi /4 11 1�[f: F=L11f% .LL
Date of l th Age If Veteran of U.S. Armed Forces,
Se �� War or Dates
I - Place of Death Hospital, Institution or
Z City, Town or Village �`--i`, R-c'e' J )-,,N L Street Address 5 1, C h 4 rL Fii tL 2 I'
La
Cf Manner of Death rtli Natural Cause El Accident ❑Homicide 0 Suicide ElUndetermined El Pending
WI Circumstances Investigation
tu Medical Certifier Name Title
Address
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Death Certificate Filed District Number Register Number 4'
City, Town or Village e,)i,f', r),l 1. l ) /I 10
iiigi ['Burial Date Cemetery or Crematory
❑Entombment 3 J ` ' :: ,': A "Lc. 1( II-,Vie
Address _
eii Cremation Q L) L"k,'it St' .> `'-'`I 1 ,N 0- d 47
Date Place Removed
Z Removal and/or Held
❑and/or
�;; Address
WI
0 Date Point of
too Li Transportation Shipment
C by Common Destination
Carrier
Oi Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ipi Permit Issued to Registration Number
ig Name of Funeral Home 1:hW ins'-% ), . ,1.4..i) e L'.s—lc;
Address J a- I`f 0.,c c' Jl--I5`4,U ice,1 P87 D
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
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11
fl' Permission is hereby ranted to dispose of the human re•ry�^'n•s described above as indicated.
SI Date Issued 31 AL., i 5 Registrar of Vital Statistics if iA9.-
�--, (signature)
Riii District Number C 3 Place 6 -yam O V
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI 3r ram✓ ��/
Date of Disposition '��- / Place of Disposition Alt � C ,l�C�
2 (address)
i
til
CC (section) (lot umber] (grave number)
Name of Sexton n Charge of Premises L< / ../ Cl
Z (pfease pri ) �.
it Signature Title046'Colle."0/1--ifiE
(over)
DOH-1555 (02/2004)