Haley, Claudette NEW YORK STATE DEPARTMENT OF HEALTH 11 517
Vital Records Section Burial - Transit Permit
J f Name First Middle Last Sex
::-M D ck.u.(ko-kle_ L . -A-VI IQ y
:r Date of Death { If Veteran of U.S. Armed Forces,
q �2Z1 , `� Age Iti1/�
War or Dates
Place of Death os a, stitution or t ' Town or Village �i I e n' s Gt it,S ddress 6 Leos a 1 Ii ±1� %%''oI
�14A�er of Deathq Natural Cause 0 Accident El Homicide 0 Suicide fl Undetermined El Pending
Circumstances Investigation
itiMedical Certifier Namet_ti_ifrct Title
-:, Address
,::.
``:° t 02- Pair 5 - G ns r-rt11s
�:�t Death Certificate Filed District Number + Register Number
G\e� L. L=�` Ci Town or Village � `�-Q�� i ( 1 N
Date Cemetery • . ..
❑Burial q 1 2
Address
.; :-4.___O
; Cremation }t e E' ��,
Date Place Removed
0❑Removal and/or Held
and/or Address
.-" Hold
ff)
Q Date i Point of
1.0 Transportation j Shipment
CS by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Renterment Date Cemetery Address
:ii:: Permit Issued to ' Registration Number
iiik Name of Funeral Home HC yna rd V: ,esker FL-wet-al ner2/ //ome, Ot i 30
Address
/i Lai-ax/et c . , C ttransbc.trcd; /Jew `%vfIc_ 1 ?04-1
Le- Name of Funeral Firm Making Disposition or to Whom
'`" Remains are Shipped, If Other than Above
Address
CC
rtk
> Permission is hereby granted to dispose of the human remains described abovq as indicated.
iii
iiiik Date Issued °t t 2-3 /(L/ Registrar of Vital Statistics
i (signature)
ilk District Number 5 Got Place 6 �u�S FC,, \.t S IV
iiio..14
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 111I;/►q Place of Disposition rn .i,, ( "-.
W (address)
f/J
CC (section) lo4 numb) (grave number)
0 Name of Sexton or Person in Charge of Premises `j its N
g (please print)
1: Signature I 4 Title C11j
(over)
DOH-1555 (9/98)