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Fedor, Lillian
f Vie NEW YORK STATE DEPARTMENT OF HEALTH it 1 Vital Records Section Burial - Transit Permit Name First • /r Middle Last Sex Date of edth /,'e,r5 c- Age If Veteran of U.S. Armed Forces, / I F/9`Q/L/ War or Dates 1-. P . e of Death /J/ Hospital, Institution or i z ity), Town or Village C W' (a l IJ Street Address /-e,r/S ��,/�-C/%'// a Manner of Deathatural Cause 0 Accident El Homicide 0 Suicide El❑Undetermined 0 Pending ILI Circumstances Investigation WMedical Certifier _\ ,. Na a (\ , / / D 5/� Title Cin /67 6c( Address_c 1,/_,.&ri e r V 7 ram! /Ac? V Death ty\ Certificate Filed �, District Number Register Number 'Ci �Town or Village �>f ifs// 6 - e/ ' 9 3 DateCe etety or Crematory / /) Burial e',i /0,_ /Jt c/y D/,7-e l/�,(4-,e C f /71 `Uc/tJ/-2,-, El Entombment Address �.X(�� Cremation 6�-al W'e ' t l,-- -6/7‘S on/ //APG'y Date Place Removed ❑Removal and/or Held and/oldor H Address 0 Date Point of 0511 Transportation Shipment 0 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to /j� ��0,/ Q7- Registration Number Name of Funeral Hom 01i 7 /�7— �' yl C - )©/'V Address 7 r f e ; J 6/ � -ze,7X i,//I 4// /A P� y Name of Funeral Firm Making Disposition or to Whom } Remains are Shipped, If Other than Above 2 Address tr LL1 • it:` Permission is he by ranted to dispose of the human remains descri edd above s i i ted. Date Issued f aRegistrar of Vital Statistics �7cr/ (signature District Number ,,3�'�`(� Place ( / U .f l �j I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k ILI Date of Disposition a)4 hi Place of Disposition s(1,., 6-cAo,.,- W (address) CA C (section) (I t number (grave number) 0 Name of Sexton or Person inCharge of Pr mises ,�,�� h ■z lease print) Signature Title COEHIft (over) DOH-1555 (02/2004)