Barnes, Rhonda NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FiK rt.ja.--Y\jet-- S. Middle Last
Sex e.
Date of Death Age - . If Veteran of U.S. Armed Forces,
3=2 j 2015 y 7 _ War or Dates
1- Place of Death Hospital, Institution or
W City, Town or Village Street Address �jS� U S �—
• Manner of Death �A Natural Cause El Accident EI Homicide El Suicide 0 Undetermined Pending
tlf Circumstances Investigation
tu• Medical Certifier Name Title
Q ,_ f G Plr 1r ke-1(r ),( M5�
Address i, V{)Jt - a . çL . I n3 c ,: 12 I
Death Certificate Filed 66{{ ���� District Nt�m1 j � Registe Numb
City, Town or Village[ Y) 6•c c 1)16; -Y� I D(P. I
❑Burial Date Ce�,ery or Crematory
3 A3 2.6/6- U'l 11 k.u1
['Entombment Address
remation
Date -�5 Place Rem ved
Z Removal and/or e
and/or Address
t Hold
Cl)
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ���� � � t G Registration J`umber
Name of Funeral Home 56519
Address �,,� //��
��[ y1 ) bon )ice__ /L`d"7U
Name of Funeral Firm Making Disposition or to ho
Remains are Shipped, If Other than Above
• Address
ILI
` Permission is h reby granted to dispose of the huma�s described abo s indicated.
Date Issued Registrar of Vital Statistics 74-1-G��r 1
gii (signature)
District Number /51 3 Place m OF i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
La• Date of Disposition 3 Vic— Place of Disposition N✓ (/J 4-✓ ��>// .ey
(address)
iii
CO
CC (section) (lot umber) (grave number)
• Name of Sexton or Pe -harge of Premises S ,'v�
Z _ (please print)
SignatuW i� Title a .�lil4-- ,j/
(over)
DOH-1555 (02/2004)