Sherman, Thelma NEW YORK STATE DEPARTMENT OF HEATH 1 It r1
Vital Records Section Burial - Transit Permit
:Mr Name First � Middle Last �h�Y'�`(1G1� I Sex �
:t.: eNMCA Jean
Date of Death 1 Age j If Veteran of U.S. Armed Forces,
> COL{ 12.5 ) 2o)Li (4 l.Q • War or Dates 1J 11}
Place of Death 1 Hospital, Institution or i-2
Citygp�tp)r Village eenStukr�I ! Street Address 5} E.V�reer\ Loa-
Manner of Death❑Natural Cause n Accident Homicide Suicide ❑Un etermined Pending
Circumstances Investigation
tnMedical Certifier Name Title —
or ID(• Ane Go.crkivi, M 17_
wo Address
` I--loscr:Svc A-4-�n0._,Q. Guy,s ct\\S, )I 1.216)
Death C rtificate Filed ' District Number ; Register Number
.•V City w Village \..ke e_f S�Ow/ / 5Co5-7 i Li
Date 1 Cemetery or Cre atory
❑Burial 041 atZ, ( av 1` ---' j e 'N e
Addr s -- - --
Cremation
3
• Date 1\1T , Place Removed
''❑Removal f and/or Held
•- and/or
Hold Address
d ! Date ` Point of
N Q Transportation i Shipment
a; by Common —Destination
Carrier
C Disinterment
Date ' Cemetery Address
Reinterment Date ' Cemetery Address
Permit Issued to ,t Fez/lei-al Registration Number
Name of Funeral Home H lna Id b: &tiAet- zei-a l home_ CI i 3L;
Address t r
it 11 Laiati C • , C i t.C_C f)sburcj , 1 Aw tJU') f `y
Name of Funeral Firm Making Disposition or to Whom I
. Remains are Shipped, If Other than Above ___I
r, Address
"' Permission is hereby granted to dispose of the human remains described above as indicated.
I
rI Date Issued t-t- a'-ao I,4- Registrar of Vital Statistics -2. 12.-0-4+:. '"t"`t --k--'
iii+: - (signature)
{ss District Number J LoS III Place (Ll tens k v AA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition alliP`i Place of Disposition r�/I I0(4..:
(address)
to
.,. (section) - ,(lot nitigber) (grave number)
a Name of Sexton or P on in Char, a of Premises d•hi Jtiati
Z (please print)
Signature Title Co30 r1
(over)
DOH-1555 (9/98)