Nordquist, Erma NEW YORK STATE DEPARTMENT OF HEALTE
Vital Records Section Burial - Transit Pernnf
:,. Name First Middle Last Sex ,
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IiiDate of Death Age If Veteran of U.S.Armed Forces,
(n- ,�} ) a01`-\ In or Dates nJ 1A
ce of Death Hospital, Institution or
own or Village a lens �ql�� Street Address Si '�n �� S}-r re}
Manner of Death 2Y Natural Cause Accident Homicide Suicide Undermined o Pending gCircumstances Investigation_
Medical Certifier Name Title
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Address
lac, 6' Dri s-f'-tf + �7 Lens fa lk,S, N y /Z8b 1
{ ath Certificate Filed Dis NumbQ / Regist um r
Town or Village (3 Ie,nS Foi 1\s mber
Date Cemetery or Crematory
i . DBurial 03 ) 1 -7 J a-o1 y .(:);n-e_ V;co c r`e.onc v -
Addr s
Cremation \,...0 �c.d pQ r i u .y, )??Uy
Date Place Removed I
i Removal and/or Held
and/or Address - v--
ig Hold
Date —point of
CO Q Transportation _ 1 Shipment
3 by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
Q Renterment Date Cemetery Address
''fikPermit Issued to Registration Number
Name of Funeral Home Ha riard v° Zaiter FLuierai Home- p!130
Address // Laf
;• 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 as indicated.
:: . Date Issued 3 ) I `t I I 'T) Registrar of Vital Statistics WC Q .A- gJ `
(signature)
" District Number 5 60 I Place 6 Lam,—s � r
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�a.,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f=
E Date of Disposition S`17-i LI Place of Disposition `NC- ,/ ,�J C A-. PIA}
a (address)
W
14
(secti of n mbar) (grave number)
GName of Sexton 11: 2:_)n' ge Premises � p�✓ �/M cal
Z ,�n / C
(please print)
Signature A� V `r '6 Title MoYL.- 4,
(over)
DOH-1555 (9/98)