Hubbard-D'Alessandro, Sharon NEW YORK STATE DEPARTMENT OF HEALTH � 3
Vital Records Section N Burial - Transit Permit
Name First Mid le L t x
-miShoran as ��u��i►�P !- Woo, IDi ec.rciro -e►�rr.C-e-
Date of Death Age If Veteran of U.S. Armed Forces,
�0'ZOj2OIl 16 War or Dates �6
Place of Death �^ Hospital, Institution or i calls i 1---
City, Town or Village GQW T t lb Street Address b !c 9l�-i
Manner of Death g Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
4,,
Circumstances Investigation
Medical Certifier Name TTr 1 C i l L e r Titt_ p
k-go Address Park 64-. G lot tisi 17SC) I
Death Certificate Filed District Number Register Number
City, Town or Village 6rI e.4 Q
❑Burial Date g IZy/20 jq Cemetery or Crematory "N' Vie;, r f �e �„l'q
0 Entombment Address ! IN 1. / 7U
IA:-,,,,,A
(Cremation Z t Ova Ley eueYl5bur r / AN l2 .k) �i
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
t Disinterment Date Cemetery Address
IllReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homef'Y\ . . 4 I tV W r A ne ) l- - cull
Address z rtr,w 100- Ed rd(, l" 1 /Z3ze
4 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 remains described above as indicated
; Date Issued b/2i4 //Y Registrar of Vital Statistics W Q>�v.ir �� "�
(signature)
;fig District Number 5& i Place G ,,,,S \LS t o Li
: I certify that the remains of the decedent identified above were disposed of in accordance " h this permit on:
Date of Disposition 6K02\ - I Place of Disposition P 1 /�YC.�k f , ,4.,t/fit,
(address)
/ (section) (lot ber) J (grave number)
{„ Name of Sexton/of er Char a of Premises ��/
ci
,; � � (please ant) A i
; Signature ��'� C Title �� lL
/
(over)
DOH-1555 (02/2004)