Finley, Betty NEW YORK STATE DEPARTMENT OF HEALTI
41 -514()
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
h L lam!L(� -- F6^!7
Date of Death Age eteran of U.S. Armed Forces,
'L / `Z ar or Dates
f- Plac ath H • stitution or T
Ci Town Village r- O L,7U,.J treet Address /'/ h/1, ��S L4,�.,cif]
p Manner-o Death Natural Cause 0 Accident El Homicide 0 Suicide Undetermined Ei Pending
W Circumstances Investigation
----- -------
W Medical Certifier Name - '' Title
Address 1 _
D Liu,- L„ c.r' 6(, 0 j- r 1 a.<1 I
O
Death Icate File Y `- District Number ; Register Number
Cit Tor Village DO 1-Ta.-.--) ,t ,gyp Wc_I `J to YO! C,
['Burial 1 Date _ I Cemetery o Crematory
Entombment] ___ 7/S 7 Z ____-__..._ [-e� L;:ji/6 ----------
Address QzSre.mation / ) a Q O 411,tuf�'" 7 l f
� _ 1)1
Date I Place Removed
Z❑and/or Removal -I and/or Held
2
Address
fa Hold
dDate Point of
N Q Transportation j _ Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to _ I Registration Number
Name of Funeral Home H ck�(f of cI 1�, 6o,ker t",._LfC r�Li tooylie___ I 011 30._
Address
11 _Cl.kk.y H . , CL,Lc'cn- 10k_..ty , tie ,,.. `yui k 12 oo_j Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above _
a Address
fr
W- - -- --
C' Permission is hereby granted to dispose of the human remains described abov as indicated.
Date Issued 7'a 'I 2- Registrar of Vital Statistics C.- j L� �A.A ,
(signature)
District Number S(o 5 O Place o
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 2)fl2( Place of Disposition Pw0u.J (writ-Or!v.—
W 7' s'(� - (address)
— —
CC (section) (lot number) (grave number)
pName of Sexton or Per on in Char e of Premises - L"i,��`QL/r 'S"�h-
Z► I (please print)
iii
Si nature _ Title Cie 4f}%o(L
t-
9
(over)
DOH-1555 (02/2004)