Fontaine, Connie NEW YORK STATE DEPARTMENT OF HEALTH I< • 4 i fi 3 1°Z-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�AJA)//.f.r 3—iK),.v r" POnS i n) v— 1677e1.6-
Date of Depth Age If Veteran of U.S.Armed Forc s,
.'//to //J _ �t'o War or Dates �f/61-
Place A( eath ital, Institution or
W City,(`I-owry1r Village AJ E5'2,3 Ce/-/Q Street Addre ,s—(' j �2 ; . RI—. 2-P A)
a Manner of Death FINatural Cause 0 Accident Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
o Kcul,u 2o/. —) P - C
Address � r
L{ -Smi9 A/7-t n.J ') a_, /v o.J c_/-1 Li /U . /2RS -a
Death C ficate Filed District Number Reg er Number
City, own' r Village , V�f-
❑Burial Date //S.—
Cemetery o Cremato
❑ tombment Address � y
12nCremation l ,_'r Ub'YL, /� & U t�`Lrit)S s&' LJ
Date Place Removed
Z❑Removal and/or Held
H and/or Address
1 Hold
O Date Point of
NQ Transportation _ Shipment
C by Common Destination
Carrier _
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1
Permit Issued to Registration Number
Name of Funeral Horn - , ker Enec a_1 { vrrYt_ O I l 3o
Address 11 LQ-cG.y Q H e SA-. , a LixenSbv,r y , Ni e v.. `Jur IL 12 si 0 y
Name of Funeral Firm Making Disposition or to Whom
F-_ Remains are Shipped, If Other than Above
Address
It
iu
Permission is hereby granted to dispose of the human remains described • ov-as i cated
Date Issued 5-p g- (< Registrar of Vital Statisticsal 1(1 ignature)
District Number /6-0 Place 1\leukomlo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 51?ei 5 Place of Disposition . ✓ �d
2 (a ress)
w
re (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premisesr ' .�a�r
Zrr (pl ase print)
iii
Signature4 Title ,`7iEmi?lL
(over)
DOH-1555 (02/2004) •