Chandler, Charlotte 11/4
NEW YORK STATE DEPARTMENT OF HEA LTk'0 * # 3 L
Vital Records Section Burial - Transit Permit
Name F st Middle L st Se
Ci9 Z-D7lG /9 C-} �� 6:--7e
Date of De Age If Veteran of U.S. Armed Forces,
/ �yvz War or Dates /,.e
}� PI a of Death Hospital, Institution or
F it own or Village �yeigi y6[/Zr//Ay Street Address 6y S fetf: , Y
0 nner of Death gNatural Cause El Accident El Homicide El Suicide �Undetermined Pending
W. Circumstances Investigation
in Medical Certifier Name Title
c#�j 7, 6_ may, /,7, D ,
Address
/a 4/ 6/rJ //-,/0y i02cvr
D th Certificate Filed �` District Number Register Number
i Town or Village �y,7S /`z2/�S L5`6.O/ • 3
Burial Date `y y Cem/ ry or Crematory
Entombment 7` " 6` /i ' " r7L- Or C.ei.
; Address
`ICremation Qve zoi-A fk //,cy / kV
Date Place Removed
Z❑Removal and/or Held
and/or Address
� ` Hold
U)
C. Date Point of
ri Transportation Shipment
G by Common Destination
Carrier
Li Disinterment Date Cemetery Address
El Reinterment Date ' Cemetery Address
Permit Issued to Registration Nimber
Name of Funeral Home y"4z 01011.� 0/710
Address
// kgitty-h- f -1 t, ictee/i3i 'y /e For
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
LEt
tar Permission is hereby granted to dispose of the human remains descri ed above as i is ted.
/6 2
Date Issued O7 )/z- Registrar of Vital Statistics / 41 Ag9`
(signature)
District Number,56Ol Place t/E'`,S ca/f/ /by /c iI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ill Date of Disposition lJn I it Place of Disposition Pe, ,Utt.., ervi_a eir146
(address)
LU
>I
III (section) (lot number) - (grave number)
CI t��
Name of Sexton or Person in Charg f Premises h, —
S.4t-
y • (please print)
W. Signature (� Title C .MNL
(over)
DOH-1555 (02/2004)