Hall, Jean NEW YORK STATE DEPARTMENT OF HEALTH _may
Vital Records Section ' - . 1,4 Burial - Transit Permit
Name Firs Middle La Sex
eAA) 4 . /IA )7 m,,14._
Date of Death Age p, If Veteran of U.S. Armed Forces,
d t c2 - �j' �O War or Dates
I Place of Death Hospital, Institution or
City, Town or Village .SC-4r-6-6 kJ Street Address pQ c,t1 u € uT> r� (—
w.
Q Manner of Death a . atural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined n Pending
Ilt Circumstances Investigation
tu Medical Certifier Name Title/I "-let oSG6 n (�
�J
/Address � � ���
/r7 1U4r °r/ IfC� v.eenl 56N,r rx /J 'Y
Death Certificate Filed District Number Register urtSber
.11 City, Town or Village c3C n)-- jy•--- /.5-3
DBurial Date ' Cemetero c Crematpry
`:< ❑ ntombment b_`30' - 7-5 V / Ai-e-I) / e-A) ek e-pr'1 A [0 ly
Address
ation
Date Place Removed
Z Removal and/or Held
❑and/or
� Address
U)
Hold
0 Date Point of
CL Q Transportationfi) Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funer I HomeEd-coPti- Z , /4-1/y n we r q 1 14141-'-- 0Q75(r(
Addres
,r\q>s-eff\--- ie
(1 C___— / /0-7 , / g cf--7 G
Name of uneral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
M.
W.
fl` Permission is he eby granted to dispose of the human re ains described a ove as indicated.
Date Issued d Registrar of Vital Statistics a. _ 4_4_12,
(signature)
District Number 153 Place / .
I certify that the remains of the decedent identified above were disposed of in ac ordance with this permit on:
atDate of Disposition GI-o- i. Place of Disposition f n e ii,'..ec.a to w►a' cit-.%,,v,
2 (address)
i)
CC (section) (lot number) (grave number)
0
ilk Name of Sexton or Person in Charge of Premises t Ow.aAly t '.rYir-kt
z (please print)
LE Signatures etc.�.v.,,.& Title Cre► P T4-
(over)
DOH-1555 (02/2004)