Civalier, Iris NEW YORK STATE DEPARTMENT OF HEALTH
11 hi--
Vital Records Section Burial - Transit Permit
Name Firs4--r'/'5 6-• Middle- ))01 fie 1—' 1 Last , SeJT.44,4 /Jt,
Date of Death Age If Veteran of U.S. Armed Forces,
`;:— 2 — 2/Y 9 a— War or Dates
Plac th // Hospital, Institution or
Ci Town Village e`er [ Street Address / /cF/ i Wil it) g 14,..._
Mannero Deathatural Cause 0 Accident 0 Homicide ❑Suicide ❑Undetermined 0 Pending
lit Circumstances Investigation
0.
la Medical Certifier Name Title
4.4 rATr/c M ri (?P 4 — C__-
,S/eUe���u
Address
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Death Ce ..si
- icate Filed DistrictNumber Registe tuber
hi Ci ri�Town r Village 6-3
ihlii['Burial Date `� etery or Cremat ry !!!
DEntombment ! l "�3 -" /7 /Nt'U' &) ?A l c Ix
Address /
ation C 0Q...Q'N3 6 or, na jr
Date / Place Removed
Z ❑Removal and/or Held
2 and/or Address
tit Hold
Clef
0 Date Point of
ttl ❑Transportation Shipment
3 by Common Destination
mi Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to g�' Registration Number
Name of Funeral H me Cgd1rA r �
1 . i f )A)orA I W� ( s/R
? Address �/
iF 30-154A-. 1,/a CG 1tY / 2-�7
Ri Name of Funeral Firm Making Disposition or to Whom 7
Remains are Shipped, If Other than Above
Address
IX
to
97 Permission is hereby granted to dispose of the human r ins described above as indicated.
Date Issued 41-62„2- Ai/1 Registrar of Vital Statistics CO-7 1 Q *A,,v(,t,
mi
(signature)
District Number (�3 Place ` 1, 4.-
.,,,,,,
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition IZ 11(o(ay Place of Disposition 4, er c j' .--
W (address)
w
I (section) 4 (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises 'ilk_
(ilease print)
Signature -.."--" Title C11601Afet
(over)
DOH-1555 (02/2004)