Bhe, Nancy E 1PiNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name [ dle . SelifiG y 1/ "ma it...
di Date of Death Age If Veteran of U.S. Armed Forces,
6 — (j 3 — lirs g/2 War or Datesd
t-. Place of Death __.�- Hospital, Institution or
Z City, Town or Village ! 1 Gal,,I (-C1-0 Street Address ,G/e�,1A& mes•. t s /i v//7i ee�/',
ilt
Manner of Death 0'Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
iii Circumstances Investigation
Ca
ta Medical Certifier Na,�J rvie r Title
Address
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Death Certificate Filed 4,7, District Number.- Register Number
City, Town or Village I I CA n)(e ro 3 cti,, Lsal
❑Burial Date i C ete or Crem tory
f — Cs-- �15 pie,0i'ek) Hp p fen-/
❑Entombment Address 6 i ,, tt
Cremation 0.e V s b 0-fry /"y'
Date Place Removed
Z Removal and/or Held
❑and/or
F Address .
Hold
IA
0 Date Point of
ti Li Transportation Shipment
a by Common Destination .
Si Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiiiiiii Permit Issued to ` Registration Number
s Name of Funeral Home illy c(. L . 4e l/ ,l crA/ m._ cps-pi
<> Address
in --3-->. 4 l'-1T77K-- A A //4--- tk-Lys /-,)_e-2 a
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'„' Address
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Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued ® I—a.S' (J 14 Registrar of Vital Statistics 2Y1 • C —.
c� (signature)
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pili District Number `.3 U V Place ! 1 c /'. J . >
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
La Date of Disposition I /i,j i c Place of Disposition gli. L► Crk-1a...,
2 (address)
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CC (section) / (lot number) (grave number)
ci Name of Sexton or Person in Char a of Premises (�` '° z}""c
zk ( lease print)
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Signature A Title CIS
(over)
DOH-1555 (02/2004)