Christian, Dolores NEW YORK STATE DEPARTMENT OF HEALTH s -‘, iT (002
Vital Records Section Burial - Transit Permit
Name it t Middle /� Last Sex.
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Date Dea Age If Veteran of U.S. Armed Forces,
_ 0 - /Y -76 War or Dates j,J O
Place of Death -� Hospital, Institution or
Z City, Town or Village 1 7-�cek%del-0\1 A Street Address 01b.5..2.5t.44)/aTTh, //a,fJTA/
Manner of Death(J Natural Cause Accident Homicide 0 Suicide Undetermined Pending
W �-"' Circumstances Investigation
la Medical Certifier Name Title
fl �/•eN e_hafic•lA� �
®o ddress ^
�rey a q 1 '-c o i0 A r ,S a-- tux-, / �3
Death Certificate Filed District Numbe Register/'3 ber
City, Town or Village GC1 jci e-01 A /, 0 `�Y((oo
Date Cemet or Crenlatory
G?Cl_ S— /��r� .
�NC (�i C•v e r ei»r N 7jV/4 El Entombment Address
;'Cremation �12ee►i,S h V r� N ,.
Date Place Rem o4ed
El Removal and/or Held
and/or Address
t Hold
CA
0 Date Point of
Transportation Shipment
Et by Common Destination
Carrier
M ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home fwAv r
c 4. 1<J/y. I ,k.Wt'io/ )(/ 1Q_-_. er9S/f
gi Address ��C rtNBYL_ )-\(\(ZE_ Ly, 0
Ui Name of Funeral Firm Making Disposition or to hom
Remains are Shipped, If Other than Above
2 Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued di- a a-a.o)'( Registrar of Vital Statistics )1 m
(signature)
District Number L5(fit, Place ) i Co d e 1-t. A
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition 41 lbity Place of Disposition gmt1L `4 4or,—
2 (address)
W
CC (section) Xsiti.......(lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises t",'
(please print)
SignatureAp
j Title ar"041
(over)
DOH-1555 (02/2004)