White, Cornelia I - {�
NEW YORK STATE DEPARTMENT OF HEALTH rl !�Vital Records Section Burial - Transit Permit
Name First r Middle Last 1 Sex..6t jt.,t
[AU(�11 e t i (,� G T-+c-
�/ "> ! Date of Death Age If Veteran of U.S. Armed Forces,
0/ —0 5" Z 01 y War or Dates Al/f-�-
Place of Death Hospital, Institution or I '�u r
City, Town or Village A r (- Street Address eleG-„' n4 V 1(C
Manner of Death atural Cause�Accident [�Homicide Ej Suicide 7Undetermined �Pending
Circumstances Investigation
tgi Medical Certifier Name Title
Ed J'
.1- G.5O be in l
Address
) 1 '5 isi 5-(-6j-e Oie 2- 6-re cc% od,,..1-. A)5" i 283y
Death Certificate Filed District Number Register ;Number
» City, Town or Village )
< ❑Burial Date 01 O jY Cemet v or Crematory
❑Entombment Address ,� ����
`:.101 Cremation 2/ Q IA4-fir' 1 Q r t,eeh.S c,-, 4 / Ov
Date Place Removed t/
am Removal and/or Held
and/or Address
Hold
44.
Date Point of
Q Transportation Shipment
s by Common Destination
Carrier
s ; Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<> Permit Issued to Registration Number
Name of Funeral Home 4o-4,yr tJa.s sa kl ru,.,",./ C`,re z K c_ 60 3 G'/
Address WO
2_ 1146, „ r 4-(/2 r c $p V% I Z
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ft
to
':' Permission is hereby granted to dispose of the human ins described above as indicate
iiln Date Issued Registrar of Vital Statistics ' `,�5, \ANc,�
(signature)
Ui District Number b l .) Place \\'c C\\4.3(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
UJ Date of Disposition ( f t IPA Place of Disposition 'C►rtVtw c o,{..
(address)
ILIA
it (section) (lot number) (grave number)
0
0 Name of Sexton or Person in Charge of Pr mises Ar,iiirf6". "rll
„Z (pl se print)
eg, Signature 4
L Title atstlitait
(over)
DOH-1555 (02/2004) '