Green, Willetta NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Narpe First tr� Middle Last
� e)e:1'Iate
l e,
Date of Death Ag If Veteran of U.S. Armed Forces,
1 - 15 -aD )` 1 War or Dates No
E- Place of Death 's Hospital, Institution o t 0� (�
W City, Town or Village G�rA\J(I K Street Address if\d 1 a_n � 1 Ter 'v u r'�(Y1q tt"� la) .
12 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifi Name Title
Q J Oros K dt 0t�Gl (Ulm
In Ail dress KlTe.r N , -I- L31 ilV)C f
Number Rt egister N mber
Death Certificate Filed District
City, Town o�Villa r a IA V t t 1 L � ,, /
❑Burial LJC1e ,(�mete?or Cre tort'
❑Entombment 07- )5-� lO) 1 T`r1Q V c L _' "61.12070 1\-i
Addres
;Cremation UlWsti,Mb
Date Place Removed
Z El Removal and/or Held
and/or
F Address
Hold
CA
O Date Point of
5 Transportation Shipment
L! by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
PermitameIssued to -cY r \ 40rY)L
DO..I(on Number
Name of Funeral Home U� j ( nC
Address �4 (Y1
u'rC d'1 5-L , ) L 1\iMy is y b
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
It
LU
C` Permission is her by granted to dispose of the human rem 'ns de 41iiid
a.•• e as indicated.
Date Issued /57� Registrar of Vital Statistics � > -, c-----
(signature)
District Number 7 6-- Place 6r pad j/p Ai (/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
LU Date of Disposition .1' 11-14 Place of Disposition ;n likt..,.., st---
a"' (address)
LU
CO
CC (section) lot number) (grave number)
Ct
fa Name of Sexton or Person in Charge of Premises Lb if
z t (p/ea�e print)
Signature - Title CtiAS14 -
(over)
DOH-1555 (02/2004)