Washburn, Anna 1
NEW YORK STATE DEPARTMENT OF HEALTH It ( 33
Vital Records Section Burial - Transit Permit
Name First A ./1iddle ' Last Sex
A.A•, /' 1 A. W 4-$4.t-Jr/`
Date of Death Age If Veteran of U.S. Armed Forces,
10/7/ a.,f gel War or Dates
a
-> Pace of Death f Hospital, Institution or //
City own or Village ��ens ���5'� Street Address (�Le�� lair �'�
anner of Death Natural Cause Accident _ Homicide Suicide Undetermin dd Pending
U Circumstances Investigation
LU Medical Certifier Name Title
fl Sk _)\ 414me& mJ
Address
! DO Pa(q7('
St'. 6-L4n> -I-A Uv� W . i to i
Death Certificate Filed / District Number Register Number
eihip Town or Village ( Le&S-F..1.� J� 5 0)
Burial Date / Cem ry or Crema ry
Q Entombment 10/ `6 6a o,4-1 I /l e V:�W (.4 r
Address /-Th
[Cremation (_,\1vLEens.4✓t A N 1.
Date v Place Removed
Di l Removal and/or Held
- and/or Address
1" Hold
Ca
O Date Point of
Ph Q Transportation Shipment
Q by Common Destination
Carrier
_ Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to . , Registration Number
Name of Funeral Horn s,K„re. 1 f t) Jam. 0o e-t'r(
Address
_ 7 , :ier-A,.4, 4ve Cofl ti ( till . 12‘3
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described aboveas indicated.
Date Issued j,/ $/c i't Registrar of Vital Statistics U..)0 "0 ' W
(signature)
District Number 5" bo j Place .S \\S + AA/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
iti Date of Disposition j0j5111 Place of Disposition ,f7gt ,4-, C(- t'b^c._
2 (address)
ill
Li)
1C (section) it.40-
, (lot numbel) (grave number)
Name of Sexton or Person in Charge of Premises stinvtfi
Z (please print)
Signature Art.._ Title Cri4Wrf-
(over)
DOH-1555 (02/2004) •