Granger, Jacquline NEW YORK STATE DEPARTMENT OF HEALTH IL '16
Vital Records Section . ..: ., Burial - Transit Permit
Name First-r Middl O o^ / /e`er ts
pie /ln ta
Date of,D�ath / Age g- If Veteran of U.S. Arm Forces,
JWar or Dates
ce of Deft Hospital, Institution o
i Town or Village Street Address / / f 14
anner of Death Undetermined P�fiding
� �iNatural Cause El El ❑Suiade ❑ ❑
LEI Circumstances Investigation
tu Medical Certifier Name / Title
nti
GOO-y-
. Addres , Ll Gk 0 611„,../tyy f 4'70
,,,
th Certificate Filed G ��ilf
District Number5 6 O tRegister Number
i , Town or ViIIa e • _
Ni Burial Dat l Q -� C x1/LV or rV t:e q/��t a Y14
❑Entombment Address i
remation �I��Eekr b JI -._ -7 12)7Q /
Date Place Removed
Z❑Removal and/or Held
and/or
Address
F= Hold
to'
Date Point of
itEI Transportation Shipment
5 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to I Registration Nu b/er
Name of Funeral Hom G/( --f ` P �I`f �/� O C 001 u7
Address PI, ! C i' Ad;-0 v (-(7)/ c44 /✓ v l
IN Name of Funeral Firm Making Disposition osition or to Whom
1 Remains are Shipped, If Other than Above
Address
CC
Ili
CL
Permission is her y anted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics L 3
(signature��� )U
IS District Number 5 60 l Place 6 (s . \ s / t u
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-
Place of Dispositiong()....0 ( a�.
l� Date of Disposition (,/$/f 6' p � •
(address)
In
to
cc (section) h"'G , .(lot
l t numbed, �",`a" (grave number)
Name of Sexton or Person in Charge of Premises �' ( .�\L*
(please print)
iij Signature Title nZiMWTD/t_
(over)
DOH-1555 (02/2004)