Hayes, Janet IT 61
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First 111jddle jLast Sex
,b,J 6-1— At^.) / /'La Er3 /,:-ram t1Gz2-
Date of Dea Age if Veteran of U.S.Afined Forces.,
iiZ? /a. 2 War or Dates .,tf A9
14 Plac th Hospit , Institution '' (�' �(j
Ci Town Village Q Ut,2,J s Q U Street A ress / / E -y -� /`� -s,jq
10
a Manner of Death RNatural Cause 0 Ac 'dent ❑Homicide Q Suicide Undetermined �Pending
IV Circumstances Investigation
0.
tti Medical Certifier Name Q Title /(/
Address
k ,„,)
Death icate Filed District Number iR t r Number
..<'< City, ow r Village t) --.SUS C7 (�.�
<' Burial Date Cemetery or Crematory)
/ Ut -`3d Z ' " .�6b� J
/
si Entombment Address �
:Cremation U B7(b�- 1213 LU&e``ASS d If L
Date Place Removed /
Q Removal and/or Held
and/or
Address
Hold
Date Point of
144 Q Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
> Permit Issued to Registration Number
<::: Name of Funeral Home MGynaf8 —0, Pir Vu kenerc .l ( 03 1°30
: 3 Address I I La�-vay Q ti e_ S-. , Q ueensbu./y , Ni e yt,.r.le_ 12 si O LA
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 above
�as indicated.
< � Date Issued \ Registrar of Vital Statistics ' ). 9--� c ( 1 3(LA.)._
` (signature)
District Numbe Place01'
>
.`" I certify that the remains of the decedent identified above were dis osed of in accord. 1 this permit on:
.:-:i Date of Disposition Z/1 iIZ Place of Disposition iAi 0Le0 ( t )rivIN_
(address)
at
(section) (lot number) (grave number)
Name of Sexton or Pers•n in Charge o Premises C.
sk r ,tN4.l�-
. (please print)
Signature
/'�J Title 02-VroATOO--
(over)
DOH-1555 (02/2004)