Fox, Joan _ tt1sD
NEW YORK STATE DEPARTMENT OF HEALTf-I - 1
Vital Records Section Burial - Transit Permit
Name First 0 Ad Middle.� �b 4. Sex
..__... ' '>< Date of De th Age vIf Veteran of U.S, Armed Forces, ..---
a
y -'?;1 -�, 1Z ( War or Dates
14 Place of Reath Hospital,Institution or
Ci , o, n%r Village 2C /L F Street Address 205- ,t) kt /U)/
p Ma - of DeathJatural Cause 0 Accident El Homicide El Suicide � Undetermined �Pending
Circumstances Investigation
LI
tu Medical Certifier ame Tit'e
ddre 61 /p / ` 1 34/'�1f�rr2 Rovi Z lD �rcN i Y
iiii Death - ificate Filed ,IL District Number 528,.. Regist\gber
ag City, o 1 or Village 0
❑Burial Date Cem fy or Cre ry � 2�
nt 61 T 3 l- eil 2 D/1 /tk �/`
❑E ombnient Address
' £remation �-" C ,2 Qt � 1�/ ZZ�t>l
Date ' Place Removed
1 7 Removal and/or Held
and/or Address
t: Hold
ti: Date Point of
Transportation Shipment
3 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
: ': 0 Reinterment Date Cemetery Address
1: Permit Issued to k/i
J Registration Number
piii FA�Name of Funeral Home Y" 1, C3 ve.&(2 Je .i.-t_ f"iE 010-7 7
Address
1:7.3 rlit,,J 5., bid / !)- 9
Name of Funeral Firm Making Disposition 6r to Whom
Remains are Shipped, If Other than Above
Address
re
to
": Permission is ereb granted to dispose of the huma mains described above as indicated.
Date Issued I Registrar of Vital Statistics Lin Ltai/(.0/\
(signature)
District Number 576h Place
" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI t)it's) rrGwfo our--
Date of Disposition q-S-i1. Place of Disposition g„t C.
(address)
W.
(section) (lot number) c� (grave number)
Name of Sexton or Person in Charge of remises Aal:ktur 3e �
z (please print)niij
iTitle CI17.“4A-TOIL
>: Signature J'6.111
(over)
DOH-1555 (02/2004) •