Dunkley, Barbara NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name(\First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
3 j - Z 0 ( 7 5 War or Dates Ii o
w- Place of Death Hospital, Institution o
W CitycTowwjr or Village -H(,(ri I t_y Street Address ' Wei—c)0 r t BricI/ 'F 1Qd
W Manner of Death®Natural Cause El Accident El Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name, Title
Irll eI Be // M i)
Address
Corrn*A /\//
Death Certificate File District Number Register Number
Cit oo pr Village4(0d I� 4-55 ,V .:),
i ❑Burial Date eter r Crema
3�� � ' r ry
❑Entombment j n Q " ' C J�� �
Address
cm
Lg(,LQ.Q_n5►J/
(.l i2�( ('y
Date J Place Removed
0❑Removal and/or Held
and/or
1 ; Hold
Address
CR
O Date Point of
6" Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to (_,, Registration Number
Name of Funeral Home �t I 'f I riC�a ! 1 Ivv}4 CI fry Oo011/
Address DV/ NU—a VS L L u7( Y L /ZcI-(e
Name of Funeral Firm Making Disposition or to Whom
1 - Remains are Shipped, If Other than Above
Address
cr
t
Permission is hereby granted to dispose of the human rein4ins described above as indic ted.
i C
Date Issued 3-2/ -/4 Registrar of Vital Statistics /'K4 ( A. (r ,-. y� „'
I� (signature)
District Number 9 S k' Place le(,¢.)n -f a cd
te' /et
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k t C Date of Disposition 34/lail Place of Disposition nttd ✓ ve ,—
u (address)
at
at
CC (section) (lot number) (grave number)
ci• Name of Sexton or Perso in Charg of Premises a„ s4
(pl ase print)
Signature Title e'17tc d►t.
(over)
DOH-1555 (02/2004)