Fontaine, Connie (2) NEW YORK STATE DEPARTMENT OF HEALTH ' ' 3�Z Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
CJA)/tr Yi9 )de �o,.s >m,.1 c 1- 71Cn.c-
Date of Depth 1 Age If Veteran of U.S.Armed Forc s,
gli(o / /J LatoWar or Dates A.)// -
1- Place,A Qeath ital, Institution or p ^ /
2 City,( ow 1r Village t ?..) c ti Q Street Addre S'"j�`z j ;. /� r. a p/V
a Manner of Death Q Natural Cause O Accident Homicide 0 Suicide O Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Address (� n r 12��-
- I `J ,3 Ali c)) ) el-. ,/U n 6
D Bath C rtificate Filed District Number Reg er Number
City, own' r Village A., J ,-i (
OSurial Date i/S"
Cemetery o Crematoa bment - /1 cF /),..)for- /
61-3
t m Address ga)tho
Cremation U Ceg-t5V U 4rgit)S &u J
Date Place Removed
O Removal and/or Held
and/or Address
or-7
Hold
Q Date Point of
thrn
LiTransportation Shipment
ea by Common Destination
Carrier _
0 Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Horn _ . ker Ful "l c_1 o �'' 0 i 1 3o _--
Address '
11 La yQi-ie S. , au.eens\a.kr f , Nie ► .Mork_ 12si0 LA
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
CZ
U
Permission is hereby granted to dispose of the human remains described - ov,,as i 4ii sated.
Date Issued 6-i$- (< Registrar of Vital Statistics it / II,.
—gnature)
District Number /,- Place 1\le wrnlo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition 51'c►ic' Place of Disposition 'CIL, ;-�t4r -
(address)
W
tr (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises 1r° ,SrY
ai-
(pl ase print)
IL/ 4 Signature Title ' S4+/3?. L
(over)
DOH-1555 (02/2004) •