Charisse, Joan fNEW YORK STATE DEPARTMENT OF HEALTHtt i vb
Vital Records Section f ' Burial - Transit Permit
i< Name First �� � �_Middle
���� Las Sex
kithi 1SStr /.-
Date of Death Al�
If Veteran of U.S.Armed Fo
f i�/�L �
2, •r Dates rc es
-14 • - of Death Hospita nstitution or r,
:-IIS IP•wn or Village L(.t''..i f 026 S ee Address Q Le'.J S F(a'u S
nner of Death(' Natural Cause Accident Homicide El Suicide Undetermined Pending
b� Circumstances Investigation
ttj Medical Certifier Name Title
Address
Po / C /to GQ /ZE-Oy
D Certificate Filed strict Num '1 R • er Number
wn or Village � i-s3 ��'l-L� I kx'
❑BUnal Date 2- ( l 2/ Cemetery r Cremato
re-.I of- t Ls-3
':❑Entombment Address
;' Cremation (,))87a. _ 0tiZ Lf%0((a I Zc�5
Date Place RemovedNEI / "
Removal and/or Held
and/or Address
Hold
0 Date Point of
[=I Transportation Shipment
by Common Destination
< 1 Carrier
Date Cemetery Address
1 Q Disinterment
<: . Date Cemetery Address
Q Reinterment
>_- ) Permit Issued to ' Registration Number
Name of Funeral Hdme G,,f itQI 8 , €c ker F ner ail ' cr _ Q1 O
=f Address
11 Lo ycHe_ S -. , Q,,Lee.nsbury , New Vol-1� t2s3o:-1
ipii Name of Funeral Firm Making Disposition or to Whom
"t Remains are Shipped, If Other than Above
Address
it
iii
Permission is hereby anted to dispose of the human remains describ ab ve a 1 "cated.
`3 Date Issued _ 2/ 2 Registrar of Vital Statistics A7A
(signature)
: District Number S(,0/ Place 6- l �, �-y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Feb Z11 1otPIace of Disposition •Ptic U, Crvw4cti _
I (address)
it (section) Ar.„. (!ot number) (grave number)
it ct Name of Sexton or Per on in Charg of Premises r' /444
/, (please print)
*a
Signature ! '' Title C eibii- ut
(over)
DOH-1555 (02/2004)