Havens, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH 2 s)
Vital Records Section Burial - Transit Permit
;=: Name First/ Middle Last I Sex
LA4)SZE- 'CC- �Av ►n iw E P5 I
litQf3Depth , Age 3 If Veteran of U.S. Armed Forces,
�-{ 1 ; War or Dates
.j ,i.'..i Place of Death I Hospital, Institution or
City, Town or Village (C..E� --S !S E 41-1 Street Address V(.E.:I-5S FA LDS 0059 s4'I-NV—
, Manner of Deathfot_Natural Cause n Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
la Medical Certifier Name Title
IP J •C%-.)> ) 1cE L D'i ovifi'• M�
r-' Address
,:i 166 ?A?--t_ T. 6 LOr) s r,ISL-ems U et / 'cSio
Death Certificate Filed I Distr t Nu tuber Register Number
iii City, Town or Village L C�S �AC_-L--� 7
Date / ] ICemetery or Crematory,
❑Burial / �j ! 6 f -'L U r E\v �Q t:n-,4- vt
Address
A.Cremation e�,a, e Raa t, But=�1.,s(�v?.L 1•a t-(
Date Place Removed
❑Remov
and/or al
2 and/or Held
N Address
0 Hold
Date ----- --.___-------T--
I Puintof
NTransportation i j Shipment
a by Common Destination
Carrier
C Disinterment Date Cemetery Address
-:: Renterment Date Cemetery Address
>' Permit Issued to ,� ` Registration Number
<' Name of Funeral Home r%�yna ICli / &Liter Fuercc/ }dome_ or) 30
NI Address i, Lal<aq€, -C of, , &t -)s&crtJ ; jUe,w tk)( L J J 3L/
•' Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
Address
re
114
I; Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 14 lb f (S Registrar of Vital Statistics CM ,--Q-WA
(signature)
t District Number 560 i Place 6 S r0.\1s, f y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition t{ /"7//r' Place of Disposition 'w,( C,, ,-,
2 (address)
w
th
CC (section) 900t number) (grave number)
pName of Sexton or Person in Charge of Premises Lh^ -Se„a. -_.
z ii;
(please print)
i . Signature is— Title (j 'w*t
(over)
DOH-1555 (9/98)