Timms, Elsie e, # *II
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FLst ,,( { Middle Last Se
E [t wl wt S
Date of D Age Q If Veteran of U.S. Armed Forces, A d
�I 1l l War or Dates ,v 1
▪ Place of Death r Hospital, Institution or �L
W City, Town or ilia; 07 C U i(('E_ Street Address 1i&CQ ( SLR 2(Uer NTT
c3 Manner of Death Natural Cause 0 Accident El Homicide 0 Suicide riUndetermined r7 Pending
Li/ Circumstances Investigation
W Medical Certifier Nam Title
a O W CIS kc u&V a M O
Address
r7 Ncd(son St' 6/CMi u 10 W32_
Death Certificat- iled ' ; District Njr Register lyufnber
City, Town or i lag: t j-I tom' .WJ (('p J !�`'� + I
EJBurial b- e r Cemetery or Crematory
Ott ( ('-f P�viv vI'e .r- Cve c.eiory
[]Entombment Address t
Cremation s Y / '�`
Date Place Removed
Z2❑Removal and/or Held
and/or Address
I Hold
CO
0 Date Point of
ri 0 Transportation Shipment
in by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
PermitameIssued to S e Q rcAi '�C1( / Registrati tuber
Name of Funeral Home /�, C Itt''l'� (�
Address -7 $evut/te l k ° llIA iv / to&a)-,
/
Name of Funeral Firm Making Disposition or to Whom
,1 Remains are Shipped, If Other than Above
2 Address
t
tL Permission is her by granted to dispose of the human remains de ,• -• • indicated.
Date Issued 14 i
Cr `f
Registrar of Vital Statistics '). it
(signature)
District Number ) Place V f t( c c 62ialit/ Ut
`�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
a� DispositionN/ti (I�( Disposition •g (
1f Date of Place of • � ,..� � rum
2 (address)
LEI
CC (section) (lot number) (grave number)
ca
Name of Sexton or Pers.n in Charge of Premises v-Ar
z (please int)
la Signature 4 1 Title Ci 01 'i—
(over)
DOH-1555 (02/2004)