Earle, Barbara NEW YORK STATE DEPARTMENT OF HEALTH Z 11
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
631L)0?619Rn K h19RL� rem 1LE
Date of Death 1A e If Veteran of U.S. Armed Forces,
I 2_�t �O Is, `1y4P.S', War or Dates W 4
14 Place o Death Hospital, Institution or
Z City, Town •r Villag j a% Street Address y0/5'�E6E-A/Gy/PIORK A/liQTJ.
0 Man - . Death Natural Cause ❑ • •dent 0 Homicide ❑Suicide ❑Undetermined ❑Pending
t W Circumstances Investigation
ia Medical Certifier Name Title
Address
436?oi90 ST.- 62b7✓S F4JLS, A/V ,/.'did l
Deat ate Filed Di trict Number' Re ister Number
Ci , Town o Village (9 c
❑Burial Date�1 /7 Cemetery or Crematory
❑Entombment Addre Q7of. �/oh►' (PJA/B EIxl e RE171 n Ta R a i _.
:Cremation c I E2Z/ Sv 6 6 d2, I/y 4 ,9 Po 9
Date Place Removed
Removal and/or Held
4 and/or
Address
{ilk
Hold
0 Date Point of
ci" 0 Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 117/9,S'O4/ FGf,c✓ `R41- h iE 0//l 7
Address
/cP Gee R Gam" S 7:1 FoagT AA IVy I oa 7
I> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
IX
la
!"` Permission is hereby ranted to dispose of the huma remains described above as indicated.
Date Issued [2 ) Registrar of Vital Statistics Q,l R 1 ,�
(signature)
District Numbercu Plac��1 C
certify that the remains of the decedent identified above were disposed of in ac rdanc with this permit on:
ILI Date of Disposition gur /el, Place of Disposition -Piqua� 607l1
Otti4,--
(address)
LEI
Ul
CC (section) (lot umber) (grave number)
Name of Sexton or Person in Charge Premises I 1,ralLe 3, 4-
(please print)
Signaturea—L Title CQt OVA
(over)
DOH-1555 (02/2004)