Chien, Jeanmne NEW YORK STATE DEPARTMENT OF HEALTH r -,,,, : Burial - Transit Permit
Vital Records Section ' ,, -
Name First Middle - Last Sex
Jeonnc__ r C hie rl
Date of Death Age - Veteran of U.S. Armed Forces,
I Z- 10.1.- I I f ' War or Dates
Place of Death (-, Hospital, Institution or p �
Citiliy, own r Village -For L d �A Street Address F,c 3r Sorm !�t.'n°„,,� Cprrl�n
i1 Manner of Death[Natural Cause n Accident 0 Homicide 0 Suicide 0 Undetermined Pending
ii Circumstances Investigation
ui Medical Certifier Name Title
UOc- cmL(;rs� M D
Address
q Cc)rc RA Cxs,Sb,,k rA ti~4 ► -Z-&D`i
Ni Death Certificate Filed District Number Register Numb
City, Town Or Village -7 5
❑Burial Date Cemete or Crematory
['Entombment12. I C�� \ Z U l.5 k,\z 0 e_.-J C re mG l�r
Address
Cremation -I a u.c;1L9_-\ R.et, _ l u.t.)_ h 51L-3L, ^i PI I Z 11
Date Place Removed
Z ri Removal and/or Held
and/or
Address
IA
Date Point of
fiLi DTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
og Permit Issued to Registration Number
iii Name of Funeral Home (Y'C- V...:4 1 M e r \---‘.4v•_s.Nes--.0 } j0Y1 e 1 c ) 4-'
Address ti
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address .
0
llii
Permission is hereby granted to dispose of the huma re ins described abov as indicated.
Date Issued /4.2 //� _.0J�� Registrar of Vital Statistics
I (signature)
Iii District Number 5755
Place
d
alint- led6002/1
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
til Date of Disposition 'Liu fir Place of Disposition g L (t4,--
2 (address)
I ,F.
C (section) � pot number)( (grave number)
Name of Sexton or Person in Charge of Premises (hr,s Stwes
(lease print)
Signature Title 1lkfidt
(over)
DOH-1555 (02/2004)