Greenmier, Evangeline NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section guriat - Transit,Permit
,�
Name First Middle f Sex_
G V► c,t L1-JCc t ►2OSi)J7)b� Ftr/7in!S'
Date of Death Age If Veteran of U.S.Armed Forces, I
P'lI��.>— 9 w War or 4 19-
p Place of Death /�f Hospital, titution
Citytki. , Town orl • Cif/Ai Yt v VI . v� Street Address ,../-,.rp i lg-..) f) Usti-_ /JL4\ ,-.5 S
Manner of Death w.Natural Cause El Accident 0 Homicide El Suicide El Undetermined Pending
1.14
Q. Circumstances Investigation
La Medical Certifier Name n) q� Title b
a /J /ti
Address i CD P C. ,_ 1'7/ 12 /
Death Certifica e_FellDistrict Number Register Number
City, Town r Village" Livug„ AD t,Lot" s 7 2-r— 21
❑Burial Date f/8 lir- Cemetery or CCrematory)
r 1.,...)e- 0 I t:i----
❑Entombment Address
Cremation U t hC b— Q l 1-6-- %S 11i / "
Date /Place Removed /J
Z❑Removal and/or Held
...� and/or Address
f= Hold
Date Point of
iL
til Q Transportation Shipment
G, by Common Destination
Carrier
Disinterment Date Cemetery Address
I:Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home'c kfO— ker F triefo...! kAOry -- 0 I I3''.
Address " Lo.:4E,Y Q.Al C SA-. , Q ki,e�nSbu.(L j , Ni e,u.S `Jur L. 12 s2 U L
Name of Funeral Firm Making Disposition or to Whom
1 . Remains are Shipped, If Other than Above
Address
Cr
LU
Permission is hereby granted to dispose of the human remains es ' ed boy s indicated.
;?j;>
' Date Issued ,$) j7 /5-- Registrar of Vital Statistics
(signature)
District Number J 7 5- Place 60,,,t/ /l,# NI
I certify that the remains of the decedent identified above w e disposed of in accordance with this permit on:
k;;;j
111 Date of Disposition �!151/r Place of Disposition �, 0v.) + duo.,_
2 (address)
Lilt
uy
pc (section) it
..(let number) , (grave number)
Name of Sexton or Person in Charge of Premises
ease print)
LEA
Signature �L Title AZ6A kliet
(over)
DOH-1555 (02/2004)