Dayton, Joanne a flier
NEW YORK STATE DEPARTMENT OF HEALTI-1
Vital Records Section Burial - Transit Permit
Name_ First MiddleLast Sex'
Date of Death Age /� If Veteran of U.S. Armed Forces,
7C/ ,I 3 2 62/1 (1% 7 War or Dates
#- Place of.Death i ;/ Hospital, Institution or
j City, kown:or Village' O0(0 /'7 Street Address-\j /4�i C.
• Manner of Deathatural Cause 0 Accident C3 Homicide El Suicide ❑Undeted Pending
ILL Circumstances Investigation
tu Medical Certifier Nam Titler4: *-q—c9 /-7 / ,,_c. 716'2 a-7/-;---i-ii, `,®/
.? ,4-i./c %‘,--e-e- ‘.%:,7cr *°....-7 -„eb .49p/'
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Death Certificate Filed District Numberi_i Register Number
-G+t , Town or lage ..�-/ ie[ jiJ 6'
❑Burial Date , or Cre ator ;.
(y �C / . .3 ) 2/\3 G� �( 7:(-7/77c� ;/-7�G�❑Entombment
Address /7
Uill cremation • / thc/Q 1 .e r A c/� � ,c��_S" ✓lV_2'!7/ 7
Date Place` Removed ��
9t ❑Removal and/or Held
and/or Address
F Hold
to
O Date Point of
t3
• Transportation Shipment
G by Common Destination
Ri Carrier .
El ElDisinterment Date • Cemetery Address
Reinterment Date • Cemetery Address
iiig ElPermit Issued to •, � � Registration Number
Name of Funeral Hom cer/`C YJ�j ,_,Z,-e6'f'77 ! -4 /,„- 0,9/x/
Address -
727/7-e S / �„ eS� 'li z ift) ,ye ' 7;>-',7 ' / f/7
1.
Name of Funeral Firm Making Disposition or to Whom
•
i4 Remains are Shipped, If Other than Above
Address
ILf
Permission is hereby granted to dispose of the human remains described above as indicated.
i Date Issued ) 3-/5' Registrar of Vital Statistics k_7,12_ (,,_ ) -ii
(signature)
Ei District Number Place ,.,-) of //7,-i c-c-
I certify that the remains.of the decedent identified above were disposed of in accordance with this permit on:
gAt I (jam I�• Date of Disposition /c i21l1 S Place of Disposition • ,.. g,
(address)
l
V
Ie (section) /1/ (lot number) (grave number)
o• Name of Sexton or Person incharge of Premises [^r' - LIA tr
(please print) ;�,�
1tl Signature v" Title -I '�IrL
(over)
DOH-1555 (02/2004)