Brill, Linda NEW YORK STATE DEPARTMENT OF HEALTH # ►
Vital Records Section Burial - Transit Permit
Name First Aiddle Last Se
Aiu,- L/ F iv>L-,(___
Date of Death l / Age/- If Veteran of U.S. Armed Fo c�,s,
S'/2-1r /I`L (..P / Wat_or Dates �4`
i-- a of Death ospital stitution orn ��us
LZtJ City, own or Village L(.4'4JS -- ° :dress (�tf,,..)-s
p nner of Death Natural Cause Accident 0 Homicide Suicide Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
a
Address
th Certificate Filed _ I District Num Register umber
Cit , own or Village U(..4' S lc/fr , S C�
Burial Date Cemetery Crematory
S— z--11//Z- P/&.)65U/
❑Entombment Address �t
Cremation (U P?GL- 4, 6W/J ✓ v7 / (.--'
❑
Date Place Removed
Z Removal and/or Held
O and/or Address
�= Hold
N
O Date Point of
NQ Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home H c).,/no,cA �, PSc aer Rirw cL I o rr't- , 01 1 30 Address
11 laAayefiC. 1 . , C;u.CCOSbu_ry , tiew 'Jul- L 12si0t--1
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above —
• Address
tt
Ui
A Permission is hereb granted to dispose of the human remains des ri ed ab e icated.
Date Issued 05—2Y/10/2_Registrar of Vital Statistics
/� (signature)
District Number 5 ?/ Place 6 ___ AY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iti Date of Disposition c I js f iZ Place of Disposition 4 , Jc)) l ea„-atar i.,
2 (address)
W
jr (section) // (lot numbter)- (grave number)
0
Name of Sexton or Pers in Charge f Premises i half Jth
Z (please print)
Signature
Title C�CM 14ZoL
(over)
-1555 (02/2004)