Davis, Gloria NEW YORK STATE DEPARTMENT OF HEALTH 11
Vital Records Section , .- , Burial - Transit Permit
ge Name Fk t 'Middle
110,E la______________ cAo Last Sex
< Date of Death Age, If Veteran of U.S. t o
/ (Z/20 1 S.
1 (PC
i S Armed Forces,
101 O i War or Dates
(., Place . •eath Hospital, Institution or
.City, , or Village . I I ,A. / Street Address S2, i ' w
Manner of Death • � � °� -L� -�� 6r_m Natural Cause ❑Accident °Homicide ❑Suicide El Undetermined Pending
val
Circumstances Investigation
Mrthedical Certifier Name Title
-:}0` Address
] IOU rac,�c,1
_r: S+.
<k:: Deat, ertificate Filed
City Tow or Village (j Q,(/�S�j(,�l/' 7 i DcIit � RegisC Number
Date( Cemetery or Crematory 1C
❑Burial l0—s 201 S
t �1 1-Qy�1
Cremation Address
....
...
:
Date I Place Removed /
Removal
0❑ and/or Held
-- and/or Address
Hold --- -
N6 Date - -- T Point of
n Transportation. ; j Shipment
n by Common I Destination
Carrier
?; 0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
': Permit Issued to 1
`' Name of Funeral Home &titer Funeral //ome Registration Number
111 Address �/ ) �0
11 Larcu-ictie fit, , &c,tc c,nsbur ; /vew L1vc)(-- ) gO
,Qi. Name of Funeral Firm Making Disposition or to Whom
z'" Remains are Shipped, If Other than Above
Address
sic
Permission is hereby granted to dispose of the human re ains described ab ve as indicated.
_' Date Issued(.Q I ) 1< Registrar of Vital Statistics
c� L -,—,
(si ture)
iiiiiiiii
>: District Numbercco ') Place 1 o i*- n G
I certify that the remains of the decedent identified above were disposed of in accordde with this permit on:
i-
Date of Disposition L 181l3' Place of Disposition eV./ �',,ld04--.
2 (address)
ifI
ta
nit (section) (tot number) (grave number)
Name of Sexton or Person in Charge of Premises A, jtNM-
Z A___LL.' (please print)
4! Signature Title Illfmt19,2
(over)
DOH-1555 (9/98)