Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Washburn, Anita
NEW YORK STATE DEPARTMENT OF HEALTH Sal Vital Records Section Burial - Transit Permit Name First A Middle Lost Se,2c- / ) Date of Death Age If Veteran of U.S. Armed Forces, u / , 0 t`t CI L' War or Dates }- Place o De Hospital, Institution or ECit , own o Village L,..k ' i�,t e r& Street Address C�I l S-ci-. C Ma eath jJ Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending W Circumstances Investigation W Medical Certifier Nam Title G }j to -lr lNS•;ay't.a.,, �wAS� AKA-.Ad ess Cucf fce•.. H( ) 13 AI.�,tr Ate, CoIt�t- A!. t I .ti . 1:.- Death Certificate Filed District Number . S Register Number I Cit ow .r Village L L,,4_ u z c,,, - 0 Burial Date / Cemetery or Cr atory /' �K S / g/ �©/`C 2 c V`c,,•�,J G�fr. '4z.v 0 Entombment Address SiCremation ��cis,v.r N:T Date 3 ' Place Removed Z❑Removal and/or Held and/or Address N Hold CD 0 Date Point of 0 Transportation Shipment G by Common Destination Carrier Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to _- - Registration Number m. Name of Funeral Home -- ` 1 ,.,,rc met k (. I-4 .', -c.._ 0 0 4,-54 Address 7 5 ke r M 0,- /4Vk• ) C,,. 0,`t" 1 a% ?2__ Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address CC fCL ail 1Permission is hereby granted to dispose of the human r a' s d cri d above ' dicated. - Date Issued j$ /g- ii Registrar of Vital Statistics t..G,Ic.i 7 ignatur / /_ District Number `�- Place c�� V / / l I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1/1 Date of Disposition f;?fI1S11K Place of Disposition ,IL Cu*vie to" (address) lj Cr (section) ,j (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises 1:0-0- St' it / (please print) Signature •./�J.�.� Title Cit/CNI (over) DOH-1555 (02/2004)