LaCross, Pauline NEW YORK STATE DEPARTMENT OF HEALTH ' bl tG 11
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
h1 PAULi YERb* t. L _Ro tiA k Cs5
Date of ' A If Veteran of U.S.Armed Forces,
ID I g. a•O 14 7 D. War or Dates '—
= Place of Death Hospital,Institution or
City,Town or Village Four �D�J hR D Street Address Fort Nk.1 o` ot4 t——s I N v cE NTG.GL
fm Manner of Deathlath_ Natural Cause Accident []Homicide D Suicide n Undetermined El Pending
s, Circumstances Investigation
. Medical Certifier Name Title
Oc r•,42-.k L AR -,iJ ofvo
Address
q CARE-\ �O QucE1.3.3 bu9z'-t- Nam. ti-agc3�-
Death Certificate Filed District Nubill5 s Registrar Nmber
City,Town or Village (p
Date tCemetery or Crer ato
Q-Burial i D 1 d� /aO I L i 1J E �I E�J � eves 476 +_`'`
Address
®Cremation ,v p.V . 'Ko A i3 ( u t e;N s Rti3 cry I K1 't ►a 8 0 y
gDate Place Removed
0❑Removal and/or Held
M and/or Address
a Hold
Date Point of
[]Transportation _ Shipment
8 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
•' Permit Issued to #� y Registration Number
Yy Name of Funeral Home Ha nand U, `e& Fun 1Qme- Of 30
z Address 1/ LQ/�
Tac/e#e of. , ( uzeisbci Alai) /vrA 1affol
: Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, if Other than Above
Address
Permission is hereby granted to dispose of the human sins described ab, ve as 'cated.
YI.
/
,; Date Issued 60[,�!.20(LI Registrar of Vital Statistics
>Y rr iii (sign re)
District Number/ 5 5 Place -Tam_ 6-6 6 E`J W cuL c
:.:.:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
5 Date of Disposition Ipjtb*If Place of Disposition e VA.,. 644�tar,....
2 (address)
ta
lA
tt (section) G 7(lot nu ) (grave number)
GName of Sexton or Person in Charge of Premises r,.f� �+r4k-
Z (please print)
# ! Signature 4_, Title eriP,,E M► %--
(over)
DOH-1555 (9/98)