Bailey, Elizabeth e er
if I
NEW YORK STATE DEPARTMENT OF HEALTH Z
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
E I zckka - e1 e I F
Date of Death 11 Age 'If Veteran of U.S.Armed Forces,
•
Off- 12•--6 2O'y ? War or Dates
Place of Death Hospital, Institution or C. , t Y J�.
.:. own or Village ('in Js F°\1 S Street Address V�+
r Manner of Death Unde#ermined Pendin
Natural Cause �Accident El Homicide D Suicide g 1
Circumstances Investigation
Medical Certifier Name Title
Er, \\ EA( //li
Address n
/vU I'✓871 '4 f'�-, C1-44~„ri. j /7 /24'd/
th Certificate Filed 1 /- District Number, ( Register ber
City, own or Village l{ L( •rS /`( (,S pQ` fv
Date ®� �O, 1 Cemetery or Crematory
Burial 1 `T` ?,lie_ V i et0 0 remit 4.Ori
Address
[Cremation t ,r A Qss'ref i N V J ( 2c"bt.t
g Date Place Removed / J
> ❑Removal and/or Held
and/or Address
Hold
Date I Point of
i L Transportation _ I Shipment
3 by Common Destination
Carrier
:':.:Q Disinterment Date Cemetery Address
- El Date Cemetery Address
Permit Issued to ! Registration Number
;, Name of Funeral Home 1'� rd I), &tker Pones/ tiOmer on 130
` Address
// Lac e le c51-. , ( “..E.e.fs ind I Ale-1-0 L/Oc)c- lagU/
Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped, if Other than Above
5 Address
`` Permission is h granted to dispose of the human r- wins d-. •-%-• - • above as indica
:I Date issued d-- Registrar of Vital Statistics - t Z C
fi
; (sign- r,
i /
District Num• 1 Place 5/WA, , ! /
I certify that the remains of the decedent identified above were d sposed of- accordance with this permit on:
f
5 Date of Disposition al aUf1W Place of Disposition A.c,it CA4r
a (address)
its
IX (section) A(171tr umber) (grave number)
Name of Sexton or Pe on in G ge of Premises i - Jo hog
g (please print)
!,9 Signature ? Title
(over)
DOH-1555 (9/98)