Taylor, Audrey NEW YORK STATE DEPARTMENT OF HEALTH s tt
Vital Records Section Burial - Transit ermit
Name First MAdle _Last Sex
bri_, 17 nil'- l Fe/7910-
Date of Death / // A � If Veteran Wo �oftUS. A ed Fore ,
es id-
- - - of Death , - ptal stitution
AIM, own or Village Otea-, -� / , )U S Street Address - t1fi%1.3 FeZ,LS
:;, 'anner of DNatural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
«a Am VD
��r
Address
c ()road Srt . Q\az _ Glcn.s 7a\`r, AL , 12-got
Certificate Filed District Number R - r umber
City, own or VillageC���-,Js F, ,s cA
Date Cemetery Cremato D Ui.Q Burial S' i y / gA)�- b.-1,)
Address r
::::Cremation ] v 07L�� v 6rCo'-.��6 U ,'11-
Date Place Removed
g Removal
and/or_Held
__
and/orliTi Address -
a Hold
0 Date I Point of
[3 Transportation Shipment
1 by Common Destination
Carrier
El Disinterment Date Cemetery Address
::..:..
Q Renterment Date Cemetery Address
Permit Issued tomes Registration Number
Name of Funeral Home Ha yna rd b. &ker Fu.,-►ercj Q/t 3 o
3 Address
• 1l Lct: U-Idle vf. , CSuQefsix-l-nd i JUe w L/04(- J '(Y/
Name of Funeral Firm Making Disposition or to Whom
,": Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains de 'bed a ve floated.
Date Issued as"OG Registrar of Vital Statistics Ahti `
(signature)//
`: District Number (0O/ Place (GJPiv. , r si�/A, /NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F tFEl Date of Disposition 5ji//4 Place of Disposition 1n"4 i J lt-'-c t<,,,_
W (address)
IA
CC (section) - (lot nurr er) (grave number)
GName of Sexton or Person - Charge of Premises t5 ., i.t'I
Z (please print) •
Signature Title Gi2/6s"19fd(Z
(over)
DOH-1555 (9/98)