DeRocher, Miriam NEW YORK STATE DEPARTMENT OF HEALTH / ?
Vital Records Section t Burial - Transit P$ermit
Name First �w Middle\ le.Last«� e - Sex
./ : .: Date of Death / Age If Veteran of U.S. Armed Forces,
1 /2 ( 11-t a.` War or Dates
•S, P ce of Death Hospital, Institution or
Town or Village �S'o3 Street Address rk` - '.p.-
Manner of Death Natural Cause O Accident O Homicide O Suicide 1-1 O Undetermined O Pending
itA LEA Circumstances Investigation
in Medical Certifier Name Title
1o1 los Address nh Certificate Filed �`O �� is M
Town or Village trict`Number Register Number
�kO �(i 0 a_. g 1-11 9
! < ['Burial Date_ Cemetery or crematory`s
OEfltombrrient Address
?'s Cremation a` O tcer-c 1� Ovckit zr.j t* %,c€loR
Date F lace Removed `
Removal and/or Held
and/or Address
E'` Hold
0 Date Point of
i Transportation Shipment
C by Common Destination
Carrier
O Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home K ,', , `..°A \\t'� - (-j`G1%
>'» Address
1 0 Ikccsi.‘n cACee - 3 Cz\e(a \-c.)\\- ,\ \t \a
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rie
WA
" Permission is�hereby ranted to dispose of the human remains described above as indicated.
Date Issued I/a l \� Registrar of Vital Statistics L�
(signatu
District Number` 0'L Place dit NI-U.Lt /
o�
I certify that the remains of the decedent identified a.ove were disposed of in accordance with this permit on:
tLI Date of Disposition 7 p) J 7 Place of Disposition /l/t (4✓ ar'-3444,/
2 (address)
rt (section) (lot nu ber) (grave number)
Cr
Name of Sexto or P in Charge of Premises5- A0,4// �`
*�r Xprint)Signatur /14 Title �l� / jcf
(over)
DOH-1555 (02/2004)