Call, Joyce NEW YORK STATE DEPARTMENT OF HEALTH # 335
Vital Records Section . .y, ' , Burial - Transit Permit
rii Name First Middle �as t ': Sex j
J oti c pN tJ - LA L� r=
Date o D th Age If Veteran of U.S. Armed Forces.
p,
5 L! /Jo i 5 t War or Dates
Place of Death ' Hospital, Institution or
�, Manner of Death
City, Town or Village �v Ct=►�Qu�`\ Street Address
- --- - —
®Natural Cause C Accident —"Homicide n Suicide n Undetermined �"Pending
Circumstances Investigation I
Medical Certifier Name Title
. - S L`t fJ ���lsh F fNl 1
Address -_-_ __ .--
L,.��S i o L cC►-.,s c3 v 2� 1� L
Death Certificate Filed -_`�
District Number • Register Number
City, Town or Village QvG.Ct. g1/4..)czLi 5USI 1ko
Date • C metery or Crematory
( Burial ,5 A 1 Do( sue
I l� � G,,1 C ___!✓yw Ki0Q27
Address
•
(. Cremation, FL � R Qc
_ - - --T — 7 �VGt Is-
' Date .._ _._ ___..
2 — Removal Place Removed — -- T
O — -- and/or 'teic
•- and/or
- - -
Hold Address
ChF_
0
Transportation Date _
=�iru •af
u) p tion - — Shipment
p by Common Destination
Carrier
� Date -__,
! i Disinterment Cemetery Address
I Reinterment ! Date Cemetery Address _1
Permit Issued to Registration Number
Name of Funeral Home: -/C.y1 is i a 1! , i'aiN - fl �,( al l j :yl
Address ---. --- - —= —
Cct� t� ,
Name ofF/ LGc �"� t, j� e j )
r` , l.J.ck.k L,7Jlc.X,i.1 C) f\-- S.i.I `1 b.�Ji- ; ' 11.1
uneral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.`
" Address _
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued S-5 - a.b15 Registrar of Vital Statistics _ --,2 . I .� - � .,
(signature) •
•
District Number 545'7 Place Q Veen v,l C
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
— — - ,.c _---- �-alarms --- — --
Date of Disposition 5/nI15' Place of Disposition
I W (address)
I
II
(section; /(lot number) (grave number)
Name of Sexton or Person in Charge of Premises ,C
ec,/ (please print;
44.1 Signature l�l Title
_ �iftA tfii+etk
over)
DOH-1555 (9/98)