Clifford, Angela NEW YORK STATE DEPARTMENT OF HEALTH 35
Vital Records Section Burial - Transit Permit
Name Fir (-kyle(
Middle st I Sex
(�e f a I°. Ci i- H' ( i F
Date of De th I 1 Age/I ^ ( If Veteran of U.S. Armed Forces,
»= I Q�_ 15 !I l�� War or Dates
i Place of Death I Hospital, Institution or no
'.2..5 City, Town or Village e FQ L 1 s Street Address C Eas4- ,l v O7k t ( 2fnf ET,P-e�
Manner of Death Natural Cause n Accident 0 Homicide 0 Suicide n Undetermined n lending
X� Circumstances Investigation
:' Medical Certifier Name av\ � Title
L
Address
-02 Pa� \L 51- • nen5 Fob A1 '1 iz80 )
•- th Certificate Filed District Number j Register Number
Town or Village G 1.v)s Eck 1\S 6/00/ i cj i
Date j Cemetery or`Crrematory
CBurial /0 / 71 1JCS Pint' View C(erY)CLk2
Address n
•>: I Cremation Ck t_SiAr ( eac__ (? U�SVi U r '' (�li
Date Place Removed /
2 — Removal I and/or ?-leid
-- --and/or Address • — ----
Hold
6i
; Date i �;;irt.o;
N. Transportation i Shipment
a by Common ( Destination —
Carrier
�,Disinterment Date Cemetery Address ,
Li Reinterment ( Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home ECUter J-ujle(Cc/ name__
Address !r LarcuLfettc
` GI ) 3L;
'i Name of Funeral Firm Making Disposition or to Whom
Z' Remains are Shipped, If Other than Above
Address
ILI
Permission is hereby granted to dispose of the human re ems des ribed abov/.5 as indicat
gi
Date lssued/O )/
7 Registrar of Vital Statistics -
<; /
(signat
>'; District Number. 7 / Place
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
EDate of Disposition to/gf I ,r Place of Disposition uit. ) (rhkfifor,...-- .
2 (address)
tn
Gi0L= (section) (lot number) (grave number)
Name of Sexton or Person in Chary)of Premises t r�y)�� t.�
J (please print)
44 Signature Title A7 -4
(over)
DOH-1555 (9/98)