St.John, Janet NEW YORK STATE DEPARTMENT OF HEALTH E - lta it 33
Vital Records Section Burial - Transit Permit
Name First---- __.. Middle Last 1 Sex
-�0� J vha r,�� S�- `Sohn
Date of Death FJ�2�'Loll 1 Age G Z ! If Veteran of U.S. Armed Forces, �- �'
War or Dates
`'` Place of Death - Hospital,nsien-er
City, C-I IenS I-Ct 11 S C,lens�al,ts P�"}-"a
;Manner of Death(,Natural Cause Accident 0 Homicide ni Suicide Undetermined Pending
-
"'! Circumstances Investigation
Medical Certifier Name Title
-- - tea V ; Cu.nn ,ngin a w1 M
Address
Death Certificate Filed District Numbed ? Regef_ umber
City. Taw,, ur Vil ayd el 1 ens Fc:L Lz /_\7
! Date 5\,z} 12-0►`i �iemeter5ror Crematory f (rx v l c
i. ElBurial
i Address
Cremation; t��kP� Zc . ( L.QQnSr y
, .01 12 RCM
': Date Place Removed - -
Removal
0 Cemova and/or Need-
I
t Hold Address
W- 1_ _._--- r_
0 Datec,mt of
N❑Transportation Shipment
6 by Common I Destination
Carrier
Disinterment Date Cemetery Address
Remterment Date Cemetery Address
Permit Issued to -\ Registration Number
Name of Funeral Home�/(/ n0 rC lr l)akel �-tne(aL/ home_ 1
Address l — — — — — CI 3C�
ii LCfC L/C-tfc 3t. , G(ALL r---) bctrc j , Ai e W t// l_ 1.2670VV I
>'] Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'46 Address
AU
gi-
Permission is hereby granted to dispose of the human remains des . ed ab ve i dicated.
`'
Date Issued Of 2 3`ZD</ Registrar of Vital Statistics
' / si ature
!i!!iili District Number 5720/ Place is.. ,47
- I
..
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
WDate of Disposition 5730 ji4 Place of Disposition ! _ -- -
a (address)
W
to -
CC
(section) �""(lot num ) (grave number)
0 Name of Sexton or Person in Charge of Premises .i,,4L
(please print)
41 Signature X Title ' CXEI Ytit
?(Dver)
DOH 1555 (9/98)