Rice, Ingalill I Pi-
NEW YORK STATE DEPARTMENT OF HEALTH ' ''s Stri
Vital Records Section Burial - Transit Permit
Name FirsMiddle Last Sex
n Ct a,I ; I t Je kv.ins ix'n -W ► f
Date of Death Age If Veteran of U.S. Armed Forces,
0�- 2--(p _ 02.e, ( L/ 7 g War or Dates /2 19
Place of Death ,n � (+ Hospital, Institution or —�
City, d• •r Village a c,�t..C-4—i?r___ Street Address I �j I VL i vV�� �
C
:. Man Death Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending‘
Circumstances Investigation
9 Medical Certifier Nam Title
ti -c Jzcef,-Sc . kit-itl�-
.. Address *- -49 V:1-Th c- 0-ck-Ck-c-t- ) \i\A( k ,--b ?---0
Death Cate Filed �� District Nymbe�� Register Number
s Cit , own r Village !O
Date Ceme Y or Crematory /
urial (� a 1 - /4( f''/'Z2t 0 eGC7 ete,n z/ ' r y
Address
LIZ Cremation a (...„-z.., t'-(2 rc E
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n if
Date Place Removed 1
2❑Removal and/or Held
E and/or Address
Fx Hold
O Date Point of
Q Transportation Shipment
C by Common Destination
Carrier
ElDisinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to r--, Registration Number
Name of Funeral Homed p si D).706 f z rod.. e ms ` c6%.3 Cp 'I
7a.A.ce f-ye. ,
imi Address Zit,' 400 5^ 4 tv. /.716.6
il Name of Funeral Firm Making Disposition or to Whom (J
Remains are Shipped, If Other than Above
Address
aC4
Permission is hereby granted to dispose of the human remains d cribed above as indicated.
ilg Date Issued ,�j—a'� --Pi Registrar of Vital Statistics a „5"-u-
iiiiii (signature)
District Number '1%5'40 Place A,, le..0 e6 .9 AQi , 17.g . tote A 6
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1
6 Date of Disposition 5 I3Df j' Place of Disposition -P UN, C.r► ( ft...d
a (address)
LLI
U)
CC (section) t numbe (grave number)
GName of Sexton or Person in Charge of Premises ri trr m -
z (please print)
LU Signature 1i‘- Title CacoNe-tdh
(over)
DOH-1555 (9/98)