Sweet, Renee r It If LC 3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Sex
aRenee S eeLa t
re . 1 e_
Date of Death Age If Veteran of U.S. Armed Forces,
// - 5 — / 'f 5/ War or Dates /�Al
}- Place of Death Hospital, Institution or ,
a City, Town or Village Gre.evt&1t tin my Street Address //ZU f- r'L. if - 1Qo(
a Manner of Death ONlatural Cause Accident Homicide 0 Suicide Undetermined �Pending
t ! Circumstances Investigation
til Medical Certifier Name Title
cit
Address c 60.114 . C)9
Death esJ u r �C / ‘�
Certificate
Filed t- District Nu 9�5 RegisteriLt er
<> City, Town or Village ��`� � 5 1--f�--
❑Burial Date CemetAry or Crematory
: ❑Entombment r i ei e (l t ew`�
Cremation Address Z l Cl..A.! GUI , a u eevi s4j c-c-^ /P
Date Place Removed i
Removal and/or Held
fl and/or
L.: Address�
Hold
0 Date Point of
i0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to c Registration Number
Name of Funeral Home C -1 Ct (CAOle ccA.4.-r,fr`-I,t �Zy,^s( CMG.
Address
11 0 t. A4 v-e 5 c.,, Sp. A-/ / 2$ C
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
E Address
UI
Permission is hereby granted to dispose of the human re . s described above as indicated.
Date Issued I 00(D JO I i-.'Registrar of Vital Statistics V.
/ v /6
(signature) IjtJ�
District Number �� Fj�j Place, ,�,, ���wak c(
ll//
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tti Date of Disposition ti rthi Place of Disposition .t;ItL�,/ tc;,lor_ .
is (address)
Ili
CC (section) (lot number) (grave number)
0
Ca ff
Name of Sexton or Person in Charge of Premises .,,41 J*A
` ( lease print)
1.0 Signature L��t Title C WE►etebr'(_
(over)
DOH-1555 (02/2004)