Lau, Winnie NEW YORK STATE DEPARTMENT OF HEALTH r. - bill
Vital Records Section Burial - Transit Permit
.51 Name First Middle Last i I Sex
W i it� L atA, i F
Date of Death Age I If Veteran of U.S. Armed Forces,
0-1Z 1 (,52 lQ , War or Dates
Place of Death ? Hospital, Institution or
Town or Village GI-CO& Fa\\S I Street Address G 1 cos �c3\\S --\-koscrActiig �
Manner of Death Natural Cause 0 Accident L_1 Homicide Ej Suicide n Undetermined n Pending
Circumstances _Investigation
Medical Certifier Name Title
cl _ ______Act e-e' o, /�_-_-- ►Ian _. I4 0
iiic Address
A 1D --- -- -P_ar\L G� .._.. �_5 __ca1 v
: z:: Death Certificate Filed , District Num i Regi ter p9r
`(Ci Town or Village C\e n S 0.\\S lQ di /�
Date r Cemetery or Crematory
0 Burial ! O— _1 +_' I)_ - ,`k P Y1. V i eu3C(`Qmi7l'1-o r
Address 1
(Cremation Vka 1/ _ _ k. Ws._01,S C'\I__-£- i __ v7
Date Place Removed
O❑Removal and/or Held
•- and/or
ii. Hold ! Address j
th
O ! Date Point of
fIni El Transportation , Shipment
a by Common Destination
Carrier
E.,Disinterment Date Cemetery Address
Reinterment l Date • Cemetery Address _
-"' Permit Issued to ' Registration Number
• Name of Funeral Home `tat/rlCt rGl L. ker FL_cneral f fOme,
Address / ( / J �7
�rl LCC.`1 i=: . , &S L kx,r)s�J(..C.rCy j , Aiau Vac I(3 2)0`� _
„ Name of Funeral Firm Making Disposition or to Whom
Fia:.v
Remains are Shipped, If Other than Above
Address
,IWN
_ v --1
!A; Permission is hereby granted to dispose of the human remains descr a ov as. ted.
,id, Date Issued 0V Registrar of Vital Statistics
€$} / (signature)
District Number jiel Place (�//its / /4 AY / Lw/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- r/
WDate of Disposition 7-(7h(4 Place of Disposition ... C-4ar:.--,
W (address)
in
CC (section) (grave number)
G Name of Sexton or Person in Charge o Premises /ibt-nurnber/1.,_
s 4•4'if
g ,f___; (please print) ��"„
4.! Signature Title Cli `a [
(over)
DOH-1555 (9/98)