Gonyea, Susen NEW YORK STATE DEPARTMENT OF HEALTH 4 * - d03
Vital Records Section Burial - Transit Permit
Name First Middle / Last Sex
S A S E P LA v_g_v4-0 60�LI EA F
Date of eath Age If Veteran of U.S. Armed Forces,
3 9(`i /o t Li 3 War or Dates
Place of Death Hospital, Institution or
City, Town or Village G LE tJ S C-40--S Street Address (y 3 I-ACL S Pos P A L—
a Manner of DeathEINatUral Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
in Circumstances Investigation
ui Medical Certifier Name Title ;1
Address
l(1 Cae c t R) c c os c o Qy it ii ( 9
lig Death Certificate Filed District Number / Register Number
iiliiiii City,Town or Village O LC NS rAL_L-S S k,( , I L((Q
El Burial Date fi /040t —
Cemetery or Crematory
❑Entombment �� / 5 p, ,,,e, t c �.) �Rt, r-, A 1 b 2`'1
Address
` [ remation_
Date Place Removed
2 El Removal ' and/or Held
174
and/orHold Address
=
t
Date Point of
0 Li Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to `� Registration Number
Name of Funeral Home (`�A N.)A 2 J P: Ai c ft 0 . I 0
Address ll
1 LA riA`1C_ rrc7 St QviE NSt3v `'1 Nr1 /3_801 _
Ifql Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
Permission is he eby granted to dispose of the human mains described above as indicat
Date Issued ' Registrar of Vital Statistics
(signature
District Number / Place
I certify that the remains of the decedent identified above wer disposed of in accordance ith this permit on:
100
Iti Date of Disposition 3-a o--is Place of Disposition -R n e v Pc j C r.e,y,A.:(o r,'L, ,,.t
3 (address)
to
I (secton (lot number) (grave number)
QQ
ct Name of Sexton or Person in arge of Premises i W�o 4-hy 1�t 'n-e at
2 ---�® (please print)
Slit ignature L1n4 &J't. Title (renlct4ory asc4-
(over)
DOH-1555 (02/2004)