LaPann, Clara NEW YORK STATE DEPARTMENT OF HEALTH d 11
Vital Records Section Burial - Transit Permit
To Name First Middle Last I Se,3,..,
Date of Death If Veteran of U.S. Armed Forces,
A k\ I a\ 1 a01•4 1 Ageco%
War or Dates —
Place of Death Hospital. Institution or
City, Town or Village OL,A_e_i- D\DL>f‘- Street Address ' ''t V\c, "vs" p...1 0 \I vfx.) LAN El
Manner of Death fzi Natural Cause I rAccident I I Homicide 0 Suicide El Undetermined El Pending
"'Circumstances ""investigation
eMedical Certifier Name 0 _ Title
E.IP
-4. Address
11'3`‘ ‘z-%0)
if Death Certificate Filed /\ f D..getnct Number Retst,-Number
• City, Town or Village l ,-)e-e ..- . .\7>(......‘"-) i `•.--\-
Date 1 Cemetery or Crematory
EiBurial II I a,4 I aot,k c),e\ia V.-e ......_, Lire %••••,..C;6'D
_
Address ,,
.:: FA Cremation 1 , et ,-.s\ 'r
t...a A t---) '''\ a Vca.
( V.....ttcs:\
-c' -;
Date 1 Place Removed
gEl Removal and/or Held
rn.'and/or Address
it. Hold
0 Date 1-Point of
ick El Transportation Shipment
Ei by Common Destination
..' . Carrier
0 Disinterment Date Cemetery Address
Reinterrnent Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mara rd b, &Ref Fcxnecal home_ Of I 3C)
liAddress a , ar P
,..*?. Latiette af• , 61U.ILE.DSbU-ado A-)e(A) thr X- /JY041 .
ILName of Funeral Firm Making Disposition or to Whom
TZ,,,,,,,,, Remains are Shipped, If Other than Above
Address
1
Permission is hereby granted to dispose of the human remains dei"-ribeMfe as indicated.
(mi Date Issued I 1 1c)-1/4-11---)0(Li Registrar of Vital Statistics--t----y----..._ .-;'\ -
(signnire)t.A.i2
N District Numberag C ) Place I t::, c., -,
. , I certify that the remains of the decedent identified above were disposed of in accorvith this permit on:
til Date of Disposition II I i(r'/At Place of Disposition gu Ud--" erv-sttini-/
M (address)
ILO
Li)
CC (section) fiat number)r. (grave number)
° Name of Sexton or Person in Charge of PremisesOlt_
CI
z & ___ (please print)
LU Signature Title CPE.APPtt
(over)
DOH-1555 (9/98)