Carter, Lillie NEW YORK STATE DEPARTMENT OF HEALTH ,: "'
Vital Records Section �' Burial - Transit Permit
Nama First Mir le Last Sex
I-4i1ie O1ca.. i 0 n e cart r R L
Date of,.eath If Veteran of U.S. Armed Forces,
titId—1 A e War or Dates ft°
- Place of Death Hospital, Institution or
ii City ow or Village 3 kld le LI Street Address ) tAX I ler A, O( tic/ PIT
13 Manner of Death K Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 1-1❑Pending
VCircumstances Investigation
at Medical Certifier Name Title
a Certifier",
Sin ioLpf6.n . MO
A ress / '+
1 Ynl - 0.e f r`tU' . �� 1 a 27_.
Death Certificate Filed i Di�tri t Number Register Number
City, ow or Village-Ho()le i5
❑Burial D4-41-1 - 0
e ' emete pr Crem ory
❑Entombment 'H n e ' 'ea) �re
ntai-e ill
aCremation Ad M 9 bl_ 1\
Date Place Removed
❑Removal and/or Held
.'4 and/or Address
i= Hold
#I)
0 Date Point of
C" Transportation Shipment
❑t
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to -'� Registration Number
Name of Funeral HomeB r"Q,1,�,°tr }u,yu,r l )`1�. '3 I'
Address �hw rh qt u f; 1. L \f'L-k_ niq9 egt,
Name of Funeral Firm Making Disposition osition or to Whom
Remains are Shipped, If Other than Above
'„ Address
ltl
P` Permission is hereby granted to dispose of the human remains described above as indicatgd.
Date Issued q- 1 L (c Registrar of Vital Statistics > 41,1, (• , =? 4
_ (signature)
District Number %155f Place Jd u%\ I-ladle/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI
Date of Disposition GI/it Jis- Place of Disposition :2Miti..J (c orf'�M
', ► (address)
Ili
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CC (section) (lot number) (grave number)
fa Name of Sexton or Person in Charge of Premises C�r„ Scup
z ( lease print)
ig Signature gt-: Title �11�►ar�
(over)
DOH-1555 (02/2004)