Roy, Agnes NEW YORK STATE DEPARTMENT OF HEALTH, iii
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Vital Records Section Burial - Transit mit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S.Armed Forces,
5-lc-,7CI11 ` if War or Dates NM
Place of Death Hospital, Institution or
5 Town or Village OuctA60,,'A Street Address 1,06,tlo )T flogo-fi (AGY s r y
13 Manner of Death®Natural Cause 0 Accident 0Homicide 0 Suicide Undetermined [J Pending
Al Circumstances Investigation
t:
Iss Medical Certifier Name Title
R05Lyn1 sowLeF M9
Address
we,.5 i motif } .Al j1t CFtiT J.C{0EGNSB0p,ki , ij `ipitt. I., " t.
Death Certificate Filed ,[ District Number Register Number
iii!iiM City,Town or Village QuaitfAviZi /- 3 6 y 5l.0 51 3`�-
°a❑Burial Date Cemetery or Crematory
❑Entombiit ''1�"aol'4 Ps� w 6v CEM EYeaf
Address
ittigiCrernation Cb N54t%I`1 , 0 `/Ol 12-I.i p ii
Date Place Removed
0 Removal and/or Held
for Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
li,!<< Permit Issued to Registration Number
Name of Funeral Home {.I1tV i.bFF Ivaitrir, Hoy, 0 Was
Address
136, i8%A,RRIN Ticlef j GC S rAu.w; 1\)y 1 A 8'01
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
fti
kV
lif Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3(11 ( -e.1<-}- Registrar of Vital Statistics yZ. IZ .'k--‘ -•
(signature)
gii District Number 5(j`1 Place T o n o' Q v e w'1S (Qv yi 0.8 (S ti
I ce that the remains of the decedent identified above were disposed of in accordance with this permit on:
tDate of Disposition`j-1 8-I`1 Place of Disposition plt(e Ii C4 '1 /
2 (address)
UI
tik
(section) - re°umber)c/J i (grave number)
Name of Sexton P in Charge of Premises
Z (Plepse Pam)A l
w (W1 Title Ckelvt 44 4- itS-T_
:::> Signature i
(over)
DOH-1555 (02/2004)