Dematties, Betty NEW YORK STATE DEPARTMENT OF HEALTH (A
Vital Records Section Burial - Transit Permit
. Name Firs# // Mid _ I ast Sex
Date of Death/Z / Age I If Veteran of U.S. Armed Force ,
�� 5— 7 •r Dates ,&)
PI ce of Death ( Hossita stitution or
ity own or Village 6&6:4j3 — I Street Address L6-r:os
,::: Manner of Death Natural �' S
Cause n Accident n Homicide Suicide n Undetermined Pending ILI
Circumstances Investigation
IIIMedical Certifier Name 110
// All Title
4n /7`a 4"tO,•) - /7 L 1-To") 11 r ,
Address
a e izz eo S . at r.,,s
iiIii D ath Certificate Filed ^ District Number
Ci own or Village I tg,,,j C- J egister Number
, � i 6oi I z1 f 8
• Date 1 Cemetery or remato
n Burial a(a// 3--- /,o Of e--v)
Address
Cremation
Date i Place Removed
❑Removal ' and/or Held _
and/or Address - --
Hold -~
rci ! Date ?cant of
aTransportation i
.VJ 0 P --- Shipment{
p by Common I Destination
Carrier
�j Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to
r Name of Funeral Home 'Eaterf- erca //om j Registration Number
Address /i LCc>< i Of 1 30
y e • , 1LLC.0 nSia-trzd - AI V X- /0g01
v Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
¢T Address
ins
gii Permission is hereby granted to dispose of the human remains described above as indicated.
A.
Date Issued 12-91 15 Registrar of Vital Statistics L130--1-yy n
(signature)
gg District Number J bQ J Place 6 s2A/N.5 ru Ws s , A/ y
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
Date of Disposition It i11i c Place of Disposition Z
LW (address)
in
Z Name of Sexton or Person in Char a of Premises (section) (lot number)iii- �� (grave number)
<<
Signature _ (please print)
Title aziolf191
(over)
DOH-1555 (9/98)