Gates, Diane NEW YORK STATE DEPARTMENT OF HEALTH 51 J
Vital Records Section f - ok Burial - Transit Perris.
Name First Middle Last Sex
Di&-tki -- ,t z. /(sr- 6' 17ES tgrlAle___
Date of Death 1 Age 7 If Veteran of U.S. Armed Forces,
Y. p _ Dates /ICI
}— Pl.ce of Death r �12--- -- -- -L---�1 A > lJ v r- _4 Hos• —
i - stitution or 4121 FaTown or Village /ptis .,a)/5 Street Address f'/wits l ,44� c i>#,
D v - ner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending .—
W __ 3N14) ___. _ _11 0
_ n _ Circumstances E Investigation
la Medical Certifier Name -124TJ-
Title
Address -__�
D-.th Certificate Filed District N ber ' Regi er ber
le Town or Village Ai
[9 1S ,
Date t rd 6 / z...._ Ce ter or rematoY
■Burial
❑Entombment'sAd ess r�
1E4Cremation i O6(ze1V /.v 7 ieOy ---
Date / 1 Place Removed
Z ri Removal i 1_and/or Held
0 and/or — — — _ -
Address
CO Hold
ODate Point of
N Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ' ( Registration Number
Name of Funeral Home H 0,I nCU cl --0, 6o,ker E-�A.r1c r«.d k c r ri— I _ I i 3 0
Address y
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address
CC
0. Permission is hereby granted to dispose of the human remains descr-bed abo e a i ated.
Date Issued /p/b//Zv/2_ Registrar of Vital Statistics _ '
^ (signature)
District Number 5�O/ Place �Ie 1flS rn�• u( CS ,,__Ckas //k /V- ,/o?�i7/
I certify that the remains of the decedent identified above were disposed ofja� in accordance with this permit on:
P Ip -- -- ,s V C W Date of Disposition Ohl it Place of Disposition u,,a oriva.
'� (address)
W
in _ _—
CC (section) , - (lot number)^ (grave number)
QName of Sexton or Person in Charg of Premises _ _________-_— ft3 t°
Zr 41—
please print)
WSignature 4 Title C I11l-)-curt _—
(over)
DOH-1555 (02/2004)