Warren, Edith d
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First 51M dle Last Sex r
L d ► 1 �r_s�.e Utre n P'
Date of Death ` Age If Veteran of U.S. Armed Forces,
D f'LZ 12Ot y `4-g War or Dates
}- Place of Death Hospital, Institution or
City, n5 h Town or Village C�2 1� S Street Address LalerrS ��05 `1P
Manner of Death ortj Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
VCircumstances Investigation
uj Medical Certifier Name Tile
0. (`'1a c'. r, akk.) , cA0 wo - D
Address
100 `I?crk- S*«e+
Death Certificate Filed District Number Register Number
City, Town or Village ,j j Q/ 3 6 5
iiig El Burial Date i �) Cemetery or Crematost
❑Entombment I ( -1 ef►neil�e� Qce�Gltor_y
Address �^
Cremation a I
[ QUG I n�� QukeenSbr M I - V
Date Place Removed
❑Removal and/or Held
and/or/or Address
CA
Hold
0 Date Point of
Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to (' Registration Number
Name of Funeral Home Ole) \Ct iw`QA kt uv`��Q 1-�e Ot o
Address
[ '-3(1) 1)1( t-I r\ 51&12...ki 30 ,k-Yte\ C- ../•S F-c-1 I S Pft I --EgOZ
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
Ill
'` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ,7 1 '3 o/ (. Registrar of Vital Statistics L,<)cM,w_,,,j (,_*/,L _
(signature)
District Number 5 3o f Place 6 (sLir,s .F-- t\ 5 t T
" I certify that the remains of the d cedent identified above wer disposed of in accor e with this permit on:
k
tI Date of Disposition 73'0 itt Place of Disposition 2/v,E._ V;i',..-/ lr
Z. (address)
111
Ca
t (section) fij
(Iqrtu I (grave number)
Name of Sexton P r n arge f Premises U IY� c
AI..
Signatur Title
CI (please oil (over)
DOH-1555 (02/2004)