Bennett, Theresa NEW YORK STATE DEPARTMENT OF HEALTH Z j
Vital Records Section t Burial - Transit Permit
Name First Middle st Sex
11nr e --e,. tR, • e.n e I-male)
Date of Death Age If Veteran of U.S. Armed Forces,
II- 17-Z0L4 9+ War or Dates nD
1- Place o Death Hospital, Institute nor ,t Airtb
City Town or VillageJQ�,n,5 Street Addressk_Try, C`'y (V t t .
ua
a Manner of Death Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined Pending
W. Circumstances Investigation
Medical Certift r[ Name • Title
ddreViKtk\A\ s�
Death -rtificate Filed I District Numb r Regist N tuber
City, ow. or Village,J DknSbu,r-J 5/-e:
❑Burial Date 1 Cemetery or Cre atory
['Entombment " _21- `4 Ti rye_V to mailD rj
Addre l_
::']Cremation uuXl.e sbi, /^r
`t
Date ) Place Removed
Z Removal and/or Held
2❑and/or
Address
UJ)
Hold
0 Date Point of
Q" 0 Transportation Shipment
C by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
T. Permit Issued to Registration Number
Name of Funeral Home tI Iex- e I 1-1-Ori jL 61199
Address(i5 57 Sia.' 'ncl tel_.!, LaJkL 1Lg42i
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
cr.
f!
"' Permission is hereby granted to dispose of the human re described abo e as indi a d.
Date Issued 1 I 1 w I i i Registrar of Vital Statistics 0 ck
(signature)
District Number S, Place h bc 1hns
"' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition ll /Z`tilN Place of Disposition ,,.f ki .-,,
(address)
LSE
tit
CC (section) il (lot number) (grave number)
Name of Sexton or Person in Charge of Premises s L v'f'
z (T S'""ease print,
Signature t' Title aiEtsilitipi
(over)
DOH-1555 (02/2004)