Aikea, JoAnne NEW YORK STATE DEPARTMENT OF HEALTH, If 22'
Vital Records Section 4 Burial - Transit Permit
Name First,_— Middle L st Sex
Date of Death / AgeIf Veteran of U.S. Armed Forces,
i i /�,v 1 i 5— 6`1 War or Dates
F j lae of Death / Hospital, Institution or /
�City� Town or Village (�lsAv ill~' Street Address c'L 5 f (1 c n
ti,- fanner of Death n Natural Cause Accident Homicide ❑Suicide Undetermined Pending
la *'' Circumstances Investigation
til Medical Certifier Name ^ Title
a /� et s- 6; LL�A; D
Address ly n
I®A. , n C 5 , Pr-, „ v;II, ,, 6 Lc-,->,- ,i. AG NI' 1 )so i
-ath Certificate Filed District NJmber Register Number _
ASP Town or Village (j Le.,y 1:)k 5 6 (31 ,S 55
. •Burial Date Cemetery or Cr atory
['EntombmentI I /'a 0 / y'.._ ,`4 e v.t w C rc 44.t to f.
Address ,
ViCremation CAAA e-e-4.>.. ) ; Me"..—)
• Date Place Removed
❑
3 Removal and/or Held
and/or Address
F+ Hold
U)
0 Date Point of
ti Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date • Cemetery Address
3 El0 Reinterment Date Cemetery Address
Permit Issued to �— Registration Number
Name of Funeral Home c.: e-A5M()rc. -f . ht O ci-'t
Address 7
--11er-IA44-,t. AiCi- .t '. ot%btL /0 1 / '6, -,)
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
Ui
Permission is hereby granted to dispose of the human remains describedd ��
above as in ' t d.
Date Issued f /d. i ) Registrar of Vital Statistics AC . v
(signature)
District Number 5-60i Place t.%L .s ± (1 Al )
J
i
'``` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition II 74s Place of Disposition L1 ,wrnsfdCa.,
l (address)
CO
Cr (section) n (lot nune'+r) (grave number)
Name of Sexton or Person in arge of Premises L ''t; t ' '
2 ((please print)
Signature Title MAO
(over)
DOH-1555 (02/2004) •