Loading...
Farley, Nancy NEW YORK STATE DEPARTMENT OF HEALTH ' �'lUi Vital Records Section Burial - Transit Permit Nap First Middle Last Sex A �r..L.a--/e.y �rma.1� h-i Date of Deaf Age If Veteran of U.S. Armed Forces, 9- 13 _/.1 (p g War or Dates 1 J° I— Place of Death Hospital, Institution or ZLLt Cit , Town or Village 1e4,1 5 Fa itS Street Address E ns 1/5 iksp►14 I 0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermif ed III Pending W Circumstances Investigation W Medical Certifier Name Title imt A4tAi— by cortr r Addr s G1�nS 1k t J Death Certificate Fileck ��„ � pp-- District Number Register Number !'Cites Town or Village kl)3 - Gt. i .5 Slob, CIA to ❑Burial Date metery or Crematory ©cr — 01—a /D yne Vt C ct ❑Entombment Address r / gCremation tleLr r vyj r/U9 t %O9 Date J Place Removed Z❑Removal and/or Held and/or Address H Hold co 0 Date Point of i." n Transportation Shipment 0 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to � Registration Number Name of Funeral Home 8 Nu) j— v tL - I +1D / in( 0 1) Address 7-4' ( hurt h St L& Lu.zer icy N ./ )o og y4, Name of Funeral Firm Making Disposition or to Whom Iiiii Remains are Shipped, If Other than Above 2, Address IX L . Permission is hereby granted to dispose of the human remains des" es ribed boy s in . e . Date Issued �('-1`� ' 7,t�IZ-Registrar of Vital Statistics / '�'<� ., (signature) District Number 5190/ Place C+/ Q-f(lam I ts I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ILL Date of Disposition ` -1`1Z Place of Disposition g „1,0140 `iv-t'dr q— 2 (address) !11 tfl ir (section) // (lot number) (grave number) Name of Sexton or Person in Cha`ee of Premises th',� ' -4 .r^�' ► (Tease print) ta Signature �- Title Chi } (over) DOH-1555 (02/2004)