Towers, Marie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First \ M,iiddle Last Sex
iv
�'`r' tom^. 0 Gtf< `3" `le-y 4 L-e.
• Date of Death Age If Veteran of U.S. Armed Forces,
R, / /. a/Y 71 War or Dates
•f Death Hospital, Institution or
/j,s !
Z •wn or Village Sots t. Street Address i 77
p , . ner of Death®Natural ¢fuse Ac indent Homicide Suicide U etermi d Pending
Ili T Circumstances �Investigation
W Medical Certifier Nam Title
0 , '1 ,1/A L f4v4s ,v fro.
Address
cc-t
e Certificate Filed �'`' District Nu er Register Number
City own or Village Jac(�{,4s- 4 .!,/
'/,.c 1
[Burial ::es11
g/ Dl Cemetery or Cre ory
❑Enmbment: s � 9� '/'L 2, /r
Cremation A-ec„S,jam'L ) /l.c, ,
Date Place Removed
Z n Removal and/or Held
9 and/or Address
H Hold
U)
0 Date Point of
Q Transportation Shipment
n by Common Destination
Carrier
Q Disinterment Date Cemetery Address•
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Ho ,1 SMo�'e-- FAA mil, L. /4)Ai...-) .) ("o`f`
Address /
S ie/v A v, L-..ar.... .Li Lac),
c)1
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
UI
5!` Permission is hereby ranted to dispose of the human rev s s ' ed a mer indica ed.
Date Issued a / f Registrar of Vital Statistics
(signature)
District Number s—c1 t Place .Sd r €,,) il J‹,
kI certify that the remains of the decedent identified abovd'were di osen accordance with this permit on:
d fi
tit Date of Disposition Q.��o f it Place of Disposition .....zoA..„ � ,�,,
(address)
ILI
CC (section) dot number) (grave number)
Name of Sexton or Person i Charge of P-emises �t ti.J
D (pieprint)
LLA
Signature Title C ."1J
(over)
DOH-1555 (02/2004)