Hewlett, Ethel NEW YORK STATE DEPARTMENT OF HEALTH' _ °z 3�J
Vital Records Section Burial - Transit Permit
Name Fathst t, 1 Midd� �' 1U`��tC ex
Date of Dea Age If Veteran of U.S. Armed Forces,
War or Dates 0\
Place of Death Hospital, Institution or
City,cn or Village U'\L�1 �Street Address Cr VA,\ N, --\--\
0 Manner of Death Natural Cause Accid 0 Homicide El Suicide riUndetermined El Pending
tt ✓ Circumstances Investigation_
ut Medical Certifier Na tle
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Addres ,
LDIC c_,,,-,,,\u h
Death ertificate File District Number Register Number
ini City, ow or Village �G,(c\1\\\ h 3'1 JLP OH-
!::ig El Burial Date 1 C ry or Crematory
❑Entombment ` `� \ \\ \
A Pit---�1 't`� 1\1-4
Address ��,, C 1
remation �..- .C—c i D 1 D -
Date Pace Remo�i d
Z❑Removal and/or Held
and/or Address
F= Hold
t
'? Date Point of
iZ Transportation Shipment
ift t
by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiiiiiiil Permit Issued to � Registration Number
pii: Name of Funeral Homes(� �'\\�/c>-, \{3 LJ)c7 o
Address
i!;0. 1-A.: 1 P ., ,,-N '. -_
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Name of Funeral Firm Makin Dis osition r to hod) .
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Remains are Shipped, If Other.than Above
Address
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"A Permission is hereby granted to dispose of the human remains described above as indicated.
in Date Issued UZ t([p I aj)l({ Registrar of Vital Statistics tS ct
J (signature)
District Number LP Place ----roL,,t- 64 caw )\-i._
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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ttI Date of Disposition Iv fil hi&( Place of Disposition T, ,,,, C„, t,.,
(address)
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CC (section) (lot number"" (grave number)
Name of Sexton or Person in Char a of Premises iacit44,- 120
Z (please print)
Signature 44.- Title Cdv OO
(over)
DOH-1555 (02/2004)
DOH-1555 (02/2004)
DOH-1555 (02/2004)