Scoville, Leona f 111 # f
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First U�� Middle Lash` I Sr
Date of Death A If Veteran of U.S. Armed Forces,
r s-1 1 --I [ )�-t I,3 War or Dates
I- Place • 5-; h Hospital, Institution or
Z Cit , Town or illag Street Address q--)C!l" �
Q Ma - . •eath Natural Cause EA ci nt n Homicide E Suicide C Undetermined
E Pending.
W Circumstances Investigation
W Medical Certifier Name Title
dress j
Dea ate File Distri 1mber Regist r 'tuber
n -/
�. Cit ,Town or illage� � �Dc
❑Bursa Date f ( Cm
eery
or Cremato
c� i1 t ci ( &V `j 1 c S L)i,e tC,cr,��'cl r.✓
t Entombment Address
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3 �Skmation i �� (a-. ��
I�� Date Place Removed
2 I—I❑Removal and/or Held
and/or Address
Hold
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0 Date Point of
NQ Transportation Shipment
aby Common Destination
- Carrier
V Date Cemetery Address
Q Disinterment
T
6141 Date Cemetery Address
ti Q Reinterment
Permit Issued to Registration Number
c Name of Funeral Home (.4. .) 5,,,i c.r �.,„,„r, ( ,-c e,--
Address
e if-,a-r iticve_ C r.-z- J. (. I `b-D--2_—
Name of Funeral Firm Making Disposition or to Whom 1
i-- Remains are Shipped, If Other than Above
2 Address
I
,314 Permission is hereby granted to dispose of the human remains described a ove as indicated.
Date Issued al. I g )i( tegistrar of Vital Statistics G Q S-. .,—,
XI 1 (signature)
District Numb J , Place ) oc�-y_N a '\- a
F=` I certify that the remains of the decedent identified above were disposed of in accordance ' this rmit on:
Z
inDate of Disposition II' JIti Place of Disposition XV 1r/,f,J C...L(c,,
2 (address)
IU
cn
i e (section) i (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises Ar,SzQ L, S1,.
Z (please print)
W Signature Title «=` 1 -
(over)
DOH-1555 (02/2004)