Hoffay, Makeisha NEW YORK STATE DEPARTMENT OF HEALT i " it it I
Vital Records Section Burial - Iran it Permit
Name First Middle Last Sex
Math.6S1na 0,q F
Date of Death Age ( If Veteran of U.S. Armed Forces,
01 Oy 244 3q War or Dates Nit}
• Place of Death i: .._pila Institution or
'?Town or Village Clte..1s R\\% Street Address ttriS Fot,11.c S.eA P;4-4I
.Y; Manner of Death Natural Cause ❑Accident 0 Homicide Q Suicide ❑Undetermined Pending
rfr Circumstances Investigation
Medical Certifier Name Title
Agec1 GI Itgn; M.D.
Address
toZ.air Smet# G l ens Fa I\s, N.y. i'Z.$+J
. Death Certificate Filed District Number Register Number
� . � Town or Village Glens F'a1\S 56oI 6
Date Cemetery orLtematoiE
`: LJ Burial 011 O 11) 12.014
R ne.V;cuo _Cr-ern a.3for 1,
Address
CremationClxeitiOLAry 1 N•/• 114134
Date Place Removed
O Q Removal and/or Held
};; and/or Address
T Hold
Date -1-Point of
7,❑Transportation j Shipment
3 by Common Destination
Carrier
iii0 Disinterment Date Cemetery Address
: 0 Reinterment Date Cemetery Address
r Permit Issued to Hay/lard Registration Number
Name of Funeral Home b, &Ref- Funeral o/}3°
:...sc Address /, La akt e (5.f'• , oute nSbu.nv r AJew
L/Urk J zzi
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
h Date Issued I 1
6 l t y Registrar of Vital Statistics (-AC L W.' --.-cTIAS:1
(signature)
4
x District Number 56 I Place 6 "s 0 c / 19)
..r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition IA I►H Place of Dispositionffi tat:
(address)
Cot/ta—
w
l :l (section) (lo um ) (grave number)
QName of Sexton or Person i harge of Premises 6-I r --X nv*
Z (please print}
t Signature 41 Title Cl2 'nelta .
(over)
DOH-1555 (9/98)