Cooper, Josephine NEW YORK STATE DEPARTMENT OF HEAtTH'f.''‘ # 1
Vital Records Section Burial - Transit Per it
Riii Name First Mppla 1 Aast Sex
,.S os61-° -)� /Yen,i Lon Pc�-rz_ FeS./7eZ
rl: Date of Depth Age If Veteran of U.S. Armed Forces,
- S'�/`� / Z 9 7 " War or Dates /7$13 - I V ro
Plac- , c-ath notion or
Ci Town • Village 36 L�,,J Street Add /cam �, S>ci,12PJv„J led, P,
aManner of DeathNatural Cause El Accident Homicide Suicide fl Undetermined Pending
Circumstances Investigation
( t Medical Certifier Name /l Title
7bJ CCU1 49-SZ&-cJi c_Z 10
<` Address
?q::: cc)ti 46/-018-0 (-qr. G 't tr-),.0
Detate Filed �j District Number egister Number
_ Ci Town Village 410 1 � ! 5
Date Cemetery o Crematory 7)
'. ❑Burial s5--/Jo /a_ r J,J UI6-1-3
Address
:;;;Cremation u�kO V a-Ass un-7 .7
Date Place Removed '
Z ri Removal and/or Held
r and/or
Hold Address
9 Date Point of
rot Q Transportation Shipment
a by Common Destination
Carrier
Li Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
< Permit Issued to Registration Number
Y Name of Funeral Home A ,� l xl is ���, Y Nam— ® I/3
Address
1111:! // (...P. 0-y4 ' c-- 0 06L.--/a.c IS Ay, /2.e-d y
i Name of Funeral F n Making Disposition or to Whom / ° "
PC PPS
Remains are Shipped, If Other than Above r"
Address
„ Permission is hereby granted to dispose of the human!:_emais described above as� indicated.
«' Date Issued .5 /O- -�,9/Z Registrar of Vital Statistics tti�c c,
aLeLiet
(signature)
S<i District Number 5 6 5:, Place( D I&,
?: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iliPaluv Crowv{
Date of Disposition S/f()It Place of Disposition � orwk..
2 (address)
Ixf
U)
CC (section) /f/ (lot number) c (grave number)
4 Name of Sexton or P son in Char a of Premises • �.�k 4- J �'
g (please print) I
LU Signature Title C( ITh.j,(i1,
(over)
DOH-1555 (9/98)