Clifton, Nancy NEW YORK STATE DEPARTMENT OF HEALTH E. /
Vital Records Section Burial - Transit Permit
Name First A // Middle Last Sex
Date of Death / Age If Veteran of U.S. Armed F. ces,
?/2 . //2- I 73 War or Date _ i 6
i-.: Place th Hospital nstitution'e r
Z CityTown o Village /`� Street Ad.ress 42,9 v1 U�1✓�SG'l E'► c3 T-..7 Qr° i32 ��/'?1 .
W Mann�ro Death�Natural Cause i Accent 0 Homicide 0 Suicide 0 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name IL Title
0. S__11r- i,-' n..) ,...CHD c--0 LOY' /1-16
Address
9 Z Qum,..)c� 64...)LC Q Ob2:.,tScz
Death C . ate Filed trict Number Re Num/Yb
City, o Village C065- -A JI 0o
El Burial Date Cemete9A Cremat
p-/2,s //2.- H ,.)
❑Entombment Address
Cremation a 097C- ; is -,,i / /(J-/
Date Place Removed
ar—i❑Removal and/or Held
and/or Address
int Hold
Date I Point of
N❑Transportation I Shipment
as by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to -- I Registration Number
Name of Funeral Home !IC+yilCU CI �. -�C/Y C(" FLL'IE'4.C. I 11(:),7 X: C I 1 , C '
Address
11 Lct-tcmjC 1 -I C i r i s i , Q k.tcc c 1,k Lu y , k'c,,,. `'c,r 1< 1 :: ()t I
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
Address
CC
ILI -
—
t!' Permission is hereb granted to dispose of the human remains described above as indicated.
Date Issuecr6 1 egistrar of Vital Statistics` G� q, (LL,..____
(signature)
District Numb ( ) Place f 7-,
I certify that the remains of the decedent identified above were disposed of in acco le with this permit on:
2
.it! Date of Disposition 4-14-i1 Place of Disposition ' .AUtr� tone"
2 (address)
ill
U)
IC (section) _ (lot number) (grave number)
GName of Sexton or Person in Charge Premises _ r,Ii e- S/ -
�► Tease print)
la Signature _ Zlit - Title _ CnirnPco
(over)
DOH-1555 (02/2004)