Brown, Ethel It
NEW YORK STATE DEPARTMENT OF HEALTH ' 1 0?Vital Records Section Burial - Transit Permit
Nam@�-�Fjrs / Middle Last Se
D e of Death A If Veteran of .S. Armed Forces,
/v - 1 ,� War or Dates
Place o`f_Death I Hospital, Institution or
City�'f own Villag- -/ f)t,../w' Street Address --F /4u A S„ , (J ti
Manner Death peatural Cause ❑Accident El Homicide 0 Suicide 0 Undetermined El Pending '
Ltd Circumstances Investigation
ta Medi gertif r Nate Title
4
1/- c:;a441CLAI fild
Deat =. i . e iled � (Reirumber District Number
City Town • Village ; C-• / gi —75
❑Bu •_ ' Date ` Cem1 ry or Crematory t (-3.12...riciAzi
❑Entombment • s- 0 orAi ���
dr:�
emation t lAA:46I /I bib V
Date y I Place Removed
a❑Removal and/or Held
and/or Address
CZ Hold
}
O Date Point of
Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Rejttria) ber
Name of Funeral Home /rZcj _ b�0 (1'
AL,
resini--A / , 1
/04A--
Name of uneral irF m Making isposition or to Whom
• Remains are Shipped, If Other than Above
• Address
' i
• Permission is her y gr t to dispose of the human m ins described a as' icated.
Date Issued/0 7 ` Registrar of Vital Statisti 4
signature)
Ogii District Number�at., Place �
:,,:: I certify that the remains of the decedent identified a were disposed of in accordance with this permit on:
lU• Date of Disposition MI !,J pf Place of Disposition 42ititt,... e.:nsr..-
x (address)
ILI
�'°'._
• , �. (section) ,i (lot number) (grave number)
0 Name of Sexton or Persor .rf C of harge Premises ^,.+ .-` '
' �r+ please print)
• Signature" / - - Title il►?
(over)
DOH-1555 (02/2004)