Place, Anna It 37,E
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Arst Middle ast Sc
Cal �n C-Q
Dale of Deatha Age Ia If Veteran of U.S. Armed Forces,
9
1 1 1 a.a/ War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Street Address
p Manner of Death> Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
in Circumstances Investigation
W Medical Certifier Name Title
�� �c,nr i IN C
Address
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De te File Dis �ulb Re is r umber
CitwnVillage L1J° lN `er
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Burial t J r� e etery or Cremato .
4,4
❑Entombment /it I e7�vl ( L* Q J �y' '0
Addres �� ( ��� a ^\ ��
C1 f 1 `1
Cremation vp_
Date Place Removed
Removal and/or Held
0 and/or
i_,-- Address
CO
0 Date Point of
al
❑Transportation Shipment
by Common Destination
o Carrier _
t ❑Disinterment
Date Cemetery Address
,,, ❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
qi Name of Funeral Home h-P.,1i`✓Lp r(_ FV-zAkAttl hi
✓vivA-Q
4. Address
S4 r-71A-0-,4 AVe , a,rim/h / 4/ Y ia-4�,
1 Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
W
14
Permission is hereby granted to dispose of the human r ins described ab e as indicated.
14
Date Issued (1.12 ua l egistrar of Vital Statistics C\__„ Q ; (1.,'
4 �� (signature)
District Numbed Q �--� Place , � a d--,...k__,
i I certify that the remains of the decedent identified above were disposed of in accordanc with t is permit on:
Z Date of Disposition p/f1I pi Place of Disposition 'f►cOdc.1 esC tarI.—
W )
U)
a (section) LA ot numb (grave number)
nName of Sexton or Person i Charge of Premises 3eitti
z (passe print)
Si g nature Title
(over)
DOH-1555 (02/2004)