Phillips, Renee 711
NEW YORK STATE DEPARTMENT OF HEALTH A I
Vital Records Section Burial - Transit Permit
, Name Firsts.) Middle Last ` Sex
Date of Death i Age ` If Veteran of U.S. Armed Forces, j
i I abh 1 4 T War or Dates _
I
Place of Death : Hospital, Institution or — _ i
City. Town or Village '�NS cAL-S Street Address G L_t ' 5 F A.L).S k6SletTAt-
fManner of Death Z Natural Cause ❑Accident 0 Homicide 0 Suicide 1---1 UndeterminedV {4
Pending
Circumstances Investigation
tjj Medical Certifier Name IP �t-� `� �v•A4 Title v D
Address
Death Certificate Filed -LE t`55 F AI I,S 1 District N er Reg Lumber
City, Town or Village ''���� i
Date / ; Cemetery or Crematory
Burial 1 a 0a / ao1Li 1 E \ tl 3 L�Rt,MAC0(Z,"‘
Address
Cremation; ak.V.V_. R V--.d Pk7 dv LE N 5 6U tZ, iJ`'\
Date - Place Removed
Z Removal i and/or eici
and/or Hold '-!
Address
4 Date girt cif
mi i Transportation ,. : Shipment _{
0 by Common t Destination
Carrier -j
D Disinterment Date Cemete Address
Date Cemetery Address
ri Reinterment
Permit Issued to ,-- .- Registration Number
ICt
Name of Funeral Home," '�1'1iia r d /? Cr t f k L,.v/ ,tz/ f,1i_-y) CI 1 3{._
Address 7- .)
. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above —__- ------_..
, Address
Permission is hereby granted to dispose of the human remains described above asinddiicated.
Nii
' Date Issued 1 2) 2 i / 4 _
{ Registrar of Vital Statistics k' v\..Q W�A: -C(0 y
(signature) v
t District Number 5601 Place _ � S U_I_��-j Itif ____..._...
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i"-
Iti1 Date of Disposition 1 R._3-1`'( .. Place of Disposition `I►14 CC a.t•.�_----12
(address)
'lc (section)
( nurpber) (grave number) t
dName of Sexton or Person in Charge of Premises "'s ,1..,„ ----. - _
Z (please print)
°U,�t
{ Signature Title Lit
over'
DOH-1555 (9/98