Nobert, Julie Aug 26 14 01:06p Enea Family Funeral Home 5185682805 p.1
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
;:Name First M'ddie Last Sex _
Date of Death Age If Veteran of U.S. Armed Forces,
g/ L//Jl-f I 7.` War or Dates
p _Place of Death Hospital, Institution or Y �e-Vo-b;\; OCh
z City, Town o Village% S\- Ja���v�,\\' Street Address
Manner of DeathratNatural Cause D Accident El Homicide ❑Suicide ❑Undetermined J Pen g
WW. Circumstances Investigation
Medical Certifier Name .-- Title IA) \3e-s-c.\4, e),ce,A.To •-, }}�� l
Address
\-10-5 (rz ,,s e.; 5� _ \ eta \3 JO\
v::' Death C
Certifica d District Number �1 Register N rnber
'•< City, Town r illy `�\-, X)\-\,c )i`\f, oW.ida ‘, \
_;1-t; Burial Date C etery or Crematory
0 U 1�t i c1,t- LS ,t v.S ��m . 0c.\.
i DEntombment-Addres
1::: Cremation ,L9..e.-t-S \QU.. f
l'" Date Place Removed
,Z L___Removal and/or Held
and/or Address
H- Hold
0 Date Point of
.D Transportation Shipment
f: � by Common Destination
Carrier
n Disinterment Date Cemetery Address
t-' ., ! Date - Cemetery Address
Reinterment
I Permit Issued to ' Registration Number
Name of Funeral Home c4\.(.Nj - 4 -Q� c0: ems\ \ cr€ l\
Address l
. �.� U-C` , fS
1�
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
2 Address
tr.
ui.. •
:i, Permission is hereby granted to dispose of the human remains de cri ed above as indicated.
s ��
Date lssuedi _ Registrar f Vital Statistic
' � I. - , 1v ' (signa-turer .
District Number L'� Piac� j
'" I certify that the remains of the decedent ide 'ified"above-truere disposed of in accordance with this permit on:
14.
Ea Date of Disposition `If 761 ly Place of Disposition C r iw---
(address)
I LUtlf
(section) (lot number) _ (grave number)
4:1Name of Sexton or Person in Charge of Premises , •, Seb
ZI please print)
Signature C/'— Title Cin woe
(over)
DCH-1555 (0212004)