Bennett, Helen NEW YORK STATE DEPARTMENT OF HEALTH 30,5-
Vital Records Section Burial - Transit Permit
Name First Midd,Le, Last Sex
Date of Death Ag -- If Veteran of U.S. Armed Forces,
L -2 D - )S War or Dates kio
I- P e of Death + j Hospital, Institution or /�
z City, own or Village G(�n5 �'C4 1 I S Street Address ��nS, 'f d ��S 6).-itt
a anner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide ❑Undetermined Pending
tit Circumstances Investigation
4 Medical Certifier i Nam Title
JDtlIe v-enS A1b
Address
7ns �a I(c tN/
Death Certificate Filed r— ( + ^ District Number Register Number
1 Town or Village �-,(ens t Q t 66 0 ) �,�
El Burial Date , L emete\rytor Crematory
['Entombment D'1 —ZZ _ ' '1 � Yl� V I-,L), C
Address
EICremation LL r)Sb .AL" 1 i
Date 1 Pla e Removed
Z ❑Removal and/or Held
2 and/or Address
t: Hold
CO
0 Date Point of
it Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to �l Registration Number
Name of Funeral Home A,f�,/ Q) 111,4,- - 1. ro 1 ) _ U 1 ( 619
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Address r ^2-C-k St- l C ) Yl d l oL!\ om )Z.g ,.
Name of Funeral Firm Making Disposition or to Whom /
1 Remains are Shipped, If Other than Above
2 Address
t
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41` Permission is hereby granted to dispose of the huma remains described a ove as i dicated
Date Issued Registrar of Vital Statistics .
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(signature)
District Numbersc)1 Place Q c. ��
I certify that the remains of the decedent identified above were disposed of in accords ce with this permit on:
Z.
IF-
W. L.
Date of Disposition I/2�t(Ir Place of Disposition , ,� �%.-
(address)
LU
CC
CC (section) %/1 (lot number) (grave number)
ciName of Sexton or Person in Charge of Premises ^/t L,Jto'
2 ( lease print)
Signature (ili Title cititti '''{
(over)
DOH-1555 (02/2004)