Stanton, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit ermit
Na First Middle Last Sex
Date of Death J Ag If Veteran of U.S. Armed Forces,
3" a3- I t4 61 + War or Dates N b
f,4Place of Death Hospital, Institution or
f City, ow r Village i-cr-I Fel u)a F5r--Street Address t i Ursi ri
WManner of Death 1 Natural Cause Accident Homicide Suicide Undetermine Pendifig
Circumstances Investigation
tit Medical Certifier Name Title
0
Address
Death Certificate Filed Distric Numbe Register Number
City ow or Village jc.t Fa -r( S� pZ(p
DBurial Date 7 f�, etery or Cremat9
❑Entombment Address-3 1 G v�4 tine Vle_t ) l O
Ni:;:;;;,Cremationl
Date 3 vPI ce Removed
Removal and/or Held
.,. and/or Address
N Hold
0 Date Point of
Q Transportation Shipment
tt by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home l5rao r �y_rn I �� J}lc 1 I
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Cr
w
9' Permission is hereb granted to dispose of the human re - s described above as indi ated.
Date Issued 3igi-I- �� Registrar of Vital Statistics G-d-i/, VI
(signature)
District Number s155 Place l t t) nOS. Gr-t Ec Lo ,rL
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition 7-/ -/(7 Place of Disposition / ktfr �t 1.4c'
lit (address)
al
Cr (section) /')(lot number) (grave number)
ct Name of Sexton Person . arge of Premises SCe (/fit/6 w-abl,., ci
2 (please print)
Signature d Title �- -'-'iii"fir). P 4s1
(over)
DOH-1555 (02/2004)