Howard, Patricia s',
NEW YORK STATE DEPARTMENT OF HEALTH 6s1
Vital Records Section Burial - Transit Permit
Name Air Middle Last i Sex
eki-, t C I k L oc.. Co ctr re> { e
Date of Death Age / If Veteran of U.S.Armed Forces, //(// ' 9 — 15 (� War or Dates 7A
Place of Death CZ the S4 tc.^ g f I a . Hospital, Institution or
City, Town or Village 1.44 r4..'n /u y Street Address 2 !�i 14 K '/71 AV
•
Manner of Death �� Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
�^
e Address tacit_ f' Kp $'. W /t ( 7�/Wt J ' /" 12527
• Death Certificate Filed
District Number Register Number
City, Town or Village
1DBurial Date
/ — c7 ` Cemetery or Crematpcy J
❑Entombment / f/; A e V t J
- Address .Cremation k40/9uPav,+S�l.Cr A.)ici
Date Place Removed
.z❑Removal and/or Held
and/or Address
Hold
y Date Point of
❑Transportation Shipment H
,, by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to / t ( / Registration Number
• Name of Funeral Home LYYN'J 495/ -,,c rcA..... rc�� (-Ave OC 3cC/
Address (,/v Pk K 5- GCe-c,(442,e. 5p . / j 28CC
• Name of Funeral Firm Making Deposition or to Whom
Remains are Shipped, If Other than Above
`'` Address
Permission is re y granted to dispose of the human rem in described a QQ s ildica ed.(CAC--
4
j Date Issued 9 `� Registrar of Vital Statistics ,.. ���"�
1 signature)
4
District Number 6:1S9 Place
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1110/i c Place of Disposition g«,.V, 64,„4 t,.+....
(address)
(section) / .(lot number) (grave number)
3 Name of Sexton or Person in Chargeof Premises thrl IL— 4144fi
lease print)
Signature L Title Otall itt42
(over)
DOH-1555(02/2004)