Haigler, Annette NEW YORK STATE DEPARTMENT OF HEALI`H
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
4A L (-- Zt • . fiu..: Lcr F
r Date of Death / Age If Veteran of U.S. Jmed Forces,
:/y 7/ �� o r J War or Dates
— P --- of Death Hospital, Institution or z` - , _ 1,
Own or Village �a Lefts 7 1)5- Street Address (9 `e•s fi� l S Pro,
,
ner of Death( Natural Cause 0 Accident [a Homicide 0 Suicide 0 Undetermined '—' F nding
� Circumstances — Investigation
Medical Certifier Name �- Title
m. C`...R th4 OA*. 8 rA� Ail I.)
Address(off /-&(ii/( G/ (- xy y
Z. Ur1 N-`1- ,aga
a-: .Certificate Filed 11� ) District Number �60 Register Number
'Ei own or Village,
Date Cemetery or Cremato
❑Burial 7� /7/ e)ar`Y ,Acv:ew oehr
Address
,�. 6i
Cremation ),eens�� 4 /
r / Nt ' oc✓(
Date Li Place Removed
— Removal and/or Held
.. - and/or Address
Hold
CQ Date Point of
Transportation - Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment 1 Date Cemetery Address
Permit Issued to r Registration Number
t Name of Funeral Home G.,S.4 1"‹. -LTA c ro / .ne t . .00`t`',
ig Address
,S Cl Ave 6r. /V. sr. (2t)
r• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:e' Address -
.1
Permission is hereby granted to dispose of the human remains describ(eeddra//bbovee//yip/s In Jglatt��JQ'd.
i:i
��>> Date Issued 7/7/it Registrar of Vital Statistics
%'' '-'-nature)
v
District Number J �0� Place 6� - - �ti1)5 /� 1 U\
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on.
Date of Disposition '7-10-Ili Place of Disposition �0JJ �+^—�r,
(address) g
.L!
sn
(section) /(lot numbe (grave number)
0 Name of Sexton or Person in Charge of Premises ��r„ . eivwf
v
. (please print)
Signature Title 04;POW I
(over)
DOH-1555 (9/98)