Knowles, Hazel r s. it 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Nam First Middle Last Sex
T ozd N, <ova) 1c5 F- ria>
Date of Death Age If Veteran of U.S. coed Forces,
I ,-1 C"' 0l�( co War or Dates
i--. P ace of Death Hospital, Institutiorysr� �� � �I
z e+ Town or Villag (f' C.71
� t L5 Street Address ( ' CG'ii C !
0 Manner of Death P1 Natural Cause El Accident 0 Homicide Suicide Undetermined Pending
W. Circumstances Investigation
W Medical Certifier ame i Title
0 - t0 ril_X___ :xtaL7 0 M�
Address
D ath Certificate Filed /1 Di trict Number Register N tuber
1Cit , Town or Village(/( J5 ?( ` p�f �j
Burial Date ) tI meter pr C`rm ry
Entombment jaLI
i T l i) . /l W ir
Addres
:Cremation Urthkir3
NV
Date (Place Removed
Z❑Removal and/or Held
42 and/or Address
i= Hold
U?
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
• Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to � ���� I � � �� Regstrati�n Number
Name of Funeral Home .}-Ll}2..( l
Address��, l i 1 � J(. L. e )G �c/
Name
000f�cFuneral Firm Making Disposition osition or to Whom
1 Remains are Shipped, If Other than Above
;, Address
ce
its
?` Permission is hereby granted to dispose of the human remains described above s indicated.
Date Issued )211 i G 19 Registrar of Vital Statistics LAD C�, Sys,
(signature
District Number Sk f Place 6�e/Z5 f�e //(17 / 2Eb j
I certify that the remains of the decedent identified above we disposed of in accord ce with this permit on:
ILJ Date of Disposition/4k)* Place of Disposition //x,r(_ (7,t /rC/vA..0
2 (add ss)
UI
CA
CC (section) lot ben) l 1 (grave number)
CV Name of Sexton o �F o Chang of Premises Q c1/ C—
(please print) y�
( Signature Titled �fJ� •
(over)
DOH-1555 (02/2004)