Cook, Sandra NEW YORK STATE DEPARTMENT OF HEALTH. 1rti *J 7 CY
Vital Records Section Burial - Transit Permit
Name First Mlle /1 Last Sex
L- (�o0
,.,/ >: Date of Death Age If Veteran of U.S. Armed Forces,
0 Li 2(o--7D I / W or Dates r-^
Place of Death ospit Institution or
ktpown or Village V Street Address Sr, ,�z:P
r of Death 'Natural Cause El Accident ED Homicide 0 Suicide IT Undetermined �Pending
1 Circumstances Investigation
iti Medical Certifier Name Title
0 .i.-14/1i Pe 3-- c1/4)-P i ertrte - 1/14,b
Address
. ).< -CO- illAi1/4401AL9 AL-i,% 441-AAA•Y Ad/V
r-; Certificate Filed District Number Register Number
i:iiii Miry own or Village A Lip-,A,J4
Burial
Date Cemeit>3jryor Ccepato
ry / ARV d� Z kit
-�
-���o IL( V (.
❑E ombnient Address
tIllrremation CP✓ft Z (21fry y j / 12.-soit
Date Place Removed
" �Removal and/or Held
it aHoldnd/or Address
ta.
Date Point of
tow L. Transportation Shipment
Ls by Common Destination
igi Carrier
Date Cemetery Address
Q Disinterment
Reinterment
Date Cemetery Address
Permit Issued to �, G (� Registrationj umber
Name of Funeral Home 111` .tat ` �'��1 - �t 0Wl C
Address f ,n j p_q
gii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'„,I~ Address
tu
tu
Permission is hereby granted to dispose of the human 7ins i s id,WO as indicated.
Date Issued y-77l-'ZD f`/ Registrar of Vital Statistics z. ,
(signature)
:>; District Number
Place lJ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ill Date of Disposition 'h 711/1 Place of Disposition FA/IL Cutlet'.,
a (address)
ta
.44
CC (section) I (lot numb , (grave number)
Name of Sexton or Person i Charge f Premises 3t'6
tit
(please print)
iii
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Signature I- Title C ipf
9
(over)
DOH-1555 (02/2004)