Cook, Ethel If
NEW YORK STATE DEPARTMENT OF HEALTH • ,4 �10,0
Vital Records Section Burial - Transit Permit
Name First / Middle Last Sex
g—TInZ L�D,,,l0- �/ - FerilgUr
Date of Death/ If Veteran of U.S.Armed Forcet
9 !/ // y A e War or Dates "
14 ce of Death Hospitat(nstitutios
Ci Town or Village , L e',,Js F Street Address j jc /0/'-s tJ3
!I anner of Death atural Cause 0 Accident n Homicide Suicide Undetermined Pending
W Circumstances Investigation
ill Medical Certifier Name Title
0
•
Address S -, ,c5 Alf 1Z�
th Certificate Filed District Number �� 'Regis r Number
City own or Village Q�t{,sr3 /9"ZG C f //7
Burial Date Cemetery remator �,
q / Z / tf I r ` -u i II//3 DEntombment
Address { ,� `
.:N remation Q U ,9'jL b l2 7 0 USN-r�3 ju
Date Place Removed t✓>ti
F. Removal and/or Held /'
❑and/or
�;; Address
Li Hold
0 Date Point of
a ElTransportation Shipment
6 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home c not 8 0, t .er Fi i r(LI c ,r ie_ Op 120 -
Address " Lcx y Q iA e 5A. , a u_censbu.r y , Iv e v-.- 'Ayr 12 sa o y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
ltil
:, Permission is hereby granted to dispose of the human remains d c ib a ve dicated.
Mi
Date Issued Oe0 1.0/Y Registrar of Vital Statistics /1
(signature)
District Number j(,0/ Place 6/� / ( A,/
` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 1J31ty Place of Disposition • ,Qc✓L. Cr.., t,.,_
2 (address)
Ili
to
CC (section) ?t number) (grave number)
CName of Sexton or Person in Charge of Premises Ao-lapivr Soiltit
111 // (pleas►print)
Signature G�1y_. Title C WE tY }TOQ
(over)
DOH-1555 (02/2004)