Ellis, Alice # 4
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
tii•,ii Name First Middle Last Sex
1 C,., 1.:'.).,--t S t L l't)4L.6
€' Date of Dea h /
Age If Veteran of U.S.Armed Forces, .
`til i / / A/ pz ica ', , War or Dates
A. Pl Hospital, Institution or
Ci wllage Street Address lAi /CJ/,/I /./6 t-A// I J
L,t
Ma eath flatural Cause El Acont 0 Homicide Q Suicide ri Undetermined r7 Pending
Circumstances Investigation
Medical Certifier Name • Title
i''�,• /2r h//}lv b .i L!r t j!-i it, A,!- Pit b
Address
Li E. h r— .1., J=e;? 1::- ))'iel iY>.i) hi, /. 1 J Y'J,
"' Dea ' ate Filed Di tt Number Register Number
>: C ,Town oVillage � s
Date I Cemetery or Crematory
:::< ❑Burial Ir•3� .i1 . 1;J1A/1=tl'LL�ti / ••
Address1 •
M::::: ®Cremation ,�;�;L hf S ra v t2A' $ •
Date Place Rerhoved
Z Removal • and/or Held
2❑and/or Address
!t Hold
Date Point of
❑Transportation Shipment
fl by Common Destination
Carrier -
:::: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
``_ Name of Funeral Home 1;t�Val/ n,i A., 1. Jay 00 SJl�t
ki.1 Address •
:}s S t2‹.v0 i\f ).A-k— IV,y,
igii Name of Funeral Firm Making Disposition or to Whom •
"" Remains are Shipped, If Other than Above
Address '
ILI
tki
It.% Permission is hereby granted to dispose of the human r ains described above as indicated.
itti Date Issued 1, I 3 bo►,A Registrar of Vital Statistics
(signature)
w> District Numbe�ls)c
''l Place ) 0 ,-.2-r\ O (\ 1.
::: I certify that the remains of the decedent identified at3ove were dispos of in accor,•. - ith this permit on:
fir ) ``''
W Date of Disposition (- S- 12 Place of Disposition I nc U � nr'
ti ' ^c to t t u
(address)
in
ce
(section) . (lot number)- (grave number)
/Jj
G Lh Name of Sexton or Pers n in Charge o Premises r,c+cQ)v r` P h rt(t-
(please print) I
t J Signatu?e Title CIZE n prToQ
(over)
DOH-1555 (9/98)