Greene, Florence 1
NEW YORK STATE DEPARTMENT OF HEALTH # q i3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
FLO/2-CitJe•lz EgMf' 6 JZ-t J i .t_(7.Ni4(_.,
Date of Death Age n If Veteran of U.S. ArmedForces,
(�2 --a.�--ZQ/�/ 7� _ War or Dates /WA
Placelof ath Hospital, Institution or
j City,Qhtlxor Village C-i Z4/.�g J., )D�� Street Address /✓021( LPL /&✓yam /Jd t4/i—
a Manner of Death Natural Cause 0 Accident El Homicide El Suicide r7 Undetermined ri Pending
Iti Circumstances Investigation
w Medical Certifier Name Title
Ib96 Peiw, 9 /VD
Address.
�/ ./A/2-4, c ' . z_4 4E 74TO c,u'') A.), / Z 93 Z-
Death Certificate Filed District Number Register Number
City, T6 or Village,EL/ZQ £%h j ouPt/ /5
0Burial Date ? Cemetery or Crematory _
DEntombment J o/Y ,,' "-"� `I/ems_ C/l(J 14 J o/-`1
Address
Cremation GZGiJ/c e./._ /L. i o e„)�e,✓u 6d,-,,,, / N l
Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
CD
0 Date Point of
EL Transportation Shipment
L by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Ntymber
Name of Funeral Home/,Ad .(CA/de /1i/(�, r2/Q 7s
Address
- 2/c) SA,Z x 4UAc. ,Q c>e. z4/c . ,e4c,/'J Ai, /-Z.9
Name of Funeral Firm Making Disposition'or to Whom J
Remains are Shipped, If Other than Above
2 Address
CC
Iffy
t::: :
Permission is hereby granted to dispose of the huma ains described above as indicated.
Siii Date Issued°3 3i' �0(1/ Registrar of Vital Statistics
signature)
District Number Assa Place J. - f j 7��
I certify that the remains of the decedent identified-- above were disposed of in accordance with this permit on:
2
III Date of Disposition /i 4 y Place of Disposition Ave_ 1`//1.•-, 0430-i
(address)
III
i (section) t ryum er)i (grave number)
ci Name of Sexton or on i ge of Premises ,c`'� /1 <"y
/ (please print)
Si � i`gnature Title 4 (over)
DOH-1555 (02/2004)