Carpenter, Susan NEW YORK STATE DEPARTMENT OF HEALTH e i 1 I/ S
Vital Records Section Burial - Transit Permit
Name First Middle Last ' Sex
Omar i ,6),,qic- C.,a.__fre --\-zc!_ t- 1
Date of Death d�+ �, 1 Age . If Veteran of U.S. Armed Forces i
y CQ War or Dates
• ' Place of_Death Hospital. Institution or /-i9-G)L 1
City, own r Village QeylSci c Street Address \K mb�,n - i-\ ___.
me Manner of Death 1 Natural Cause Accident —1 Homicide 11 Suicide fl Undetermined Pending
s`� Circumstances Investigation
Medical Certifier Name Title
M�
RosL1n. Scorn\
Address 1
U3e5kri101),r1} tk F b ,ram, 10 1 12$'U`4
Death -rtificate Filed District Number ? Register Number
Cit Town •r Village �I �(.9 SC. • 6 Co
Date I Cemetey or Crematory
I
fl Burial CA- Z F.%'n e- ALLeiNI__l reri\ ---
Address
Cremation
Date j Place Removd
Z t-"Removal and/or Held
I---and/or
1~ Address
Hold
0 ' Date �::mt at
Nn Transportation Shipment
6 by Common Destination
Carrier
m
Disinterment ' Date Cemetery Address
nReinterment Date Cemetery Address
Permit Issued to l J _Y Registration Number
; Name of Funeral Home Hasa 10 D- 3a4Ke( rw era HoM(r � 01 1 c— — 1
Address _
// LaTa,.yette .a-i-. , �Lci_,-)s L,c j , /tiea) Liv.-P` , ..7.?Gt1
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
Permission its her by granted to dispose of the human remains describ sl above as indicated.
Date issuea t RC) I Registrar of Vital Statistics el _ T
_____-- .1 (signal )
District Number Place ��
•
I certify that the remains of the decedent identified above were disposed of in accordance w th this permit on:
f
toDate of Disposition .11011 Place of Disposition es. _ . ___ -
2 (address)
LUJ
U)
cr. (section) i(lot numb ) (grave number)
Name of Sexton or Person inCharge of Premises _____ P zlr� .,Ar4
f2 (please print)
r
W Signature �?� Title C (41D(_.
i
oven
DOH 1555 (9f98