Peticolas, Carole NEW YORK STATE DEPARTMENT OF HEALTH „it. If -J f.J
Vital Records Section Burial - Transit Permit
w<: Name First G Mi le ,/�Last 1 Sex ifili
Date of Death I l Age ; If Veteran of U.S. Armed Forces, '
I L. 13 // 7 3 War or Dates _
Place I� th 1 Hospital, Institution.
City, Town*Village Q 1.)&"-WrAIS Q Street Address /, ��,9 JT i - __ -_ -
Manner of Deat N n atural Cause Acci ent n Homicide 0 Suicide ri Undetermined ID Pending
III Circumstances Investigation
Medical CertifierNamen _______
Title
-41 oSkr, S OCCAoS i\rk _ _ _
a. Address 1 1 C
> J 4c.„,TO'% NuCs'om loN. t ._ J-‘t�1ti14" AV'(-- CG."H.Stiri`j.. ,
i Death ate Filed `, ' District Number I Register Number
Cit , Town o illage k.Qe iAd')I irlk C1,4
1 Date `,� '`� Crematory C I Cemetery ry J �i
Cl Burial ! ` v_---.: �__----- 1^J a- (J1b
Address
_Q
firemation Z.
_ UYI--x_, A5Date Plai
ce Removed
Z Removal and/or Held
,... and/or _ __-------
i,,, ': Address
Hold _
0 ' Date ?Clint of I
Q Transportation Shipment
Q by Common EDestinatiort
Carrier
Disinterment Date CemeteryAddress
_
t !Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
Name of Funeral Home Ha ria.I C &leer Ft-wer(L/ Nome
Address
ll LC >rCti-U fC, o+. , &L,L(..e.1)Sta I(J , /Uew tkcX l AY/
I `Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above
Address
a
'A. Permission is hereby granted to dispose of the human r aids described ov as indicated.
Date issued 1a -►5- ►A Registrar of Vital Statistics a_,�
(sign...re)
.
3 District Number C ucq Place I®U JYI .40 '0.. _ —
I certify that the remains of the decedent identified above re disposed of in acc• Banc- with this permit on:
f-
tDate of Disposition IL/I(.'/y Place of Disposition IM.J+—✓ rs..,10( ________
2 (address)
w
U:) -
CC (section) (lumber) cat
(grave number)
C/ Name of Sexton or Perso in Charge of Premises _`_ L rn'$'o j u!<►�`
2 (please print)
{ILl Signature Title Cizt>raVA
over)
DOH-1555 (9/98)