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Pepin, Cecile ' 4F ( 17 , NEW YORK STATE DEPARTMENT OF HEALTH q 1 Vital Records Section r 'r Burial - Transit Permit Name First (1 MMAc,litsdle) Csb' A) Se(. C' IL'F Date of Death �/ If Veteran of U.S. Armed Forces, , ' 6—� t?p - Ag) / 6 War or Dates f Place of Death w"--- Hospital, Institution or" gibitc)3PLAU 5 City,`ow •r Village a� fU Street Address I oIli tit, Manner of Death latural Cause Accident Homicide Suicide �Undetermined Pending 1G! Circumstances Investigation ill Medical Certifier Name itl ress 9 ,i ve F,tLs- az,` m y 1 `/ Death ificate Filed i '1'crt , cti...Ja..ct District Number Regi number City own r Village ...7 5 5 I U DBurial Date Cem Cre o • 4 7�-;o-"?-o/y Nr ii ❑Entombment Address remation 24 ePUR CWL. 4 QA.`/ LzSo LI • Date 1 Place Removed ❑Removal 1 and/or Held and/or , Address Hold IA 0 Date Point of ei Q Transportation Shipment L by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address ig Permit Issued to +A,, Registration umber Name of Funeral Home V"` Kt- it/it/k4414-1-- 1lOfr1E C, /©-7d Address 1 ate, PIA/N q tom, �� 124-1,L_S /)/i 3 `> Name of Funeral Firm Making Disposition or to Whom • I Remains are Shipped, If Other than Above Address Cr Permission is hereby rante to dispose of the human re ins describedabove as i dic ed. Date Issued Q'7 aQ.2.0/ Registrar of Vital Statistics GHited�//__ 6 (signature) District Number 5'7 55 Place ae t Edw I certify that the remains of the decedent identified above were disposed of in a cordance with this permit on: 1 >.: Z ��,l Date of Disposition 7.3D `/ Place of DispositionAve Y f � - Ir 4ey a (address) fil lit / (section4 (l t numb r) (grave number) el Name of Sexton� P�son arge Premises � W �� z (p/e se print) t Signature ,`.ii( Title _ Cere-Winiald2 Y- . t (over) DOH-1555 (02/2004)' '