Daves, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH 4 (,('?
Vital Records Section Burial - Transit Permit
Na7), First a Middle n Last ex
Date Dea h Age If Veteran of U.S. Arined Forces,
1 7
/ 30/ D. S2— War or Dates 1,0
Place of Death Hospital, Institution r L11��
f City ow r Village LOrlJ Lcu Street Address -5 "Ve-j a
Manner of- eath'Natural Cause 1111 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
LIJ Circumstances Investigation
V Medical Certifi r Name Title
CI Mack Shure i K. NA D
Address
t) nc h0.i'►V40A) N
I
Death Certificate FiI Di trict Number Reg ter Number
City,„- Tow or Villa eL l-aK. f' 1
Burial Date Cee tery or Crematory
DEntombment 1 al 1t1 k 1 T" ! yv V 1F''.l.V Cre4'Vlfa.i
Address
[premation UU e f 5 b u(1 N
Date /Place Removed
Z ri Removal and/or Held
Rand/or Address
F_ Hold
CO Date Point of
a' Transportation Shipment
0
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1...4 L 1 LeA- rn&. 01/C c1
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
LAI 1
Permission is hereby granted to dispose of the human rem "ns described above as indicated.
Date Issued )d O`i♦ la
I
Registrar of Vital Statistics
si nature
( 9 )
District NumberQOS(e Place ,,1 4 Lo 01 Lcu
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1 .
Z
ill Date of Disposition I2,-11-tt Place of Disposition ZL/ .) Covwtfar-
(address)
1.11
CA
CC (section) 4 (lot number) C (grave number)
Name of Sexton or Person in Charge of Pr mises I ivislufivr � nrflF
z 4L.---
(please print)i11 Signature Title atm WPC
(over)
DOH-1555 (02/2004)