Burton, Carol NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Ficst Middle Last Sex
l.U(0 ` Vl in �Ur+o v) -E
>_ Date of Death 0 Age If Veteran of U.S. Armed Forces,
(123 War or Dates
P ce'of Death �_�('. �� Hospital, Institution or
, i wi i or v IIa t)J Gt f�I i 9 S Street Address g 5 NI -� Arta-, Ma v`j 5 �fa v&i
anner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
tgi Medical Certifier Nam Title
gt „ air VA O W YV1(0✓1 MID
Address
iiiiiii t 0 2 CO-M. SA-, G k 1 S F�-( I s ) ,v NiD th Certificate Filed(_ `� Senjs
District Number Register Number_
wrror� ltage 0 c9c3
Date __,,
emato y .,
❑burial Z ry%
g (Entombment Address
`�� I� V t V�
gi( ,Cremation Q IA.Gd k-c.( 0 GLA Qu-,Le M.5 6 , t'y1 /J
Date Place Removed
Removal ' and/or Held
itanHd/or Address
old
Date Point of
e40 Transportation Shipment
by Common Destination
ii!iiiiii_3 Carrier
` El Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �/ Registration Number
` j Name of Funeral Home �G�(S �itl_uck_:I I I o vi 0 1( 36
iiiiii
Address ` Lai R /l.X^ ,5, �- Q LlU.f'1,SINA 6 ),,�,�Ni`` Name of Funeral Firm king Disposition or to Whom
10* Remains are Shipped, If Other than Above
E. Address
IZ
t
Permission is hereby granted to dispose of the human remain ' eova s indicated_--
<: ,
__ S ��ii i//_ Date Issued �� Registrar of Vital Statistics ,
„,41.
(signature)
District Number �S--Dy Place �rr �pri iris
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
Date of Disposition 5/idir Place of Disposition enta� ( Or
(address)
iii
r (section) /j .(lot number (grave number)
Name of Sexton or Person in Charge o Premises `�, +
(please print)
Signature Title (Themex
(over)
DOH-1555 (02/2004)