Dice, Ginger NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
€ Name First Miai]iisJ,dle st Sew.
_> Date of Death 7- -- Age If Veteran of U.S. Armed Forces,
0/01///Z to& War or Dates Ad
} : Place of Death Hospital, Institution or
Z City, Town or Village 4f ieg,/ Street Address , ./7 ' �u% ,
Manner of Death LE Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
1 Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed , �C D strict Number Register Number
City, Town or Village . ,, r (I
Date q� Cietery or Crematory "9
❑Burial �;(i//z— 7-G - (/ ram rCl2.4 r e--7-r-
Address
Cremation -L.y r , (-NC)
Date Place Removed 1
0❑Removal and/or Held
�- and/or Address
Hold
Q Date Point of
N❑Transportation Shipment
Es by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiiii Permit Issued to c Registration Number
Name of Funeral Home / �z�, ,, 17z w ®/44-44-
iiiiii Address
Bii
/ 41.E -- ai, - �rG�l (a 1p
c�
mi Name of Funeral Firm Making,Oisposition or to Whom
It Remains are Shipped, If Other than Above _
Address
ii
Permission is hereby granted to dispose of the human re ins describe ove a indicat .
' [ Date Issued gig I i a- Registrar of Vital Statisticsiiiiiig JCS% �
/' Ssggnature} , � I
5 .L Place c3 ol� U G 3 i---`�'l,4 Ot)1 aC
>:: District Number 1 -e
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1F-
W Date of Disposition 1.1-0L Place of Disposition .V1c,Vr'
ttO C',.,fiCrt�.
(address)
LLi
CC (section) (tot number (grave number)
GName of Sexton or Person in Cha a of Premises 01(rv'r� k if
g (please print) 1'
t Signature L Title CL1t .AIo.GU(,
DOH-1555 (10/89) p. 1 of 2 VS-61