Brandt, Sallie If
NEW YORK STATE DEPARTMENT OF HEALTH , , " , qci
Vital Records Section Burial - Transit Permit
Name First Idle st Sic
eLtitr /%1,-) erl.40"/13 17 1-6-ng-1_6--
Date of Death / Age If Veteran of U.S.Armed Force /
= !i 1 S War or Dates
k Place o eath Hos•ital, Institution orii y�
Ci Town Village Street Addres- & , /`/dv',,.in9i-J / 1.
g Q��,�s� /37
Manner of Deatf Natural Cause Accid t Homicide Suicide Undetermined Pending
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CA !f'� Circumstances Investigation
iii Medical Certifier Name //��c1 Title M
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Address n g 4 n /- 3 1,tva I
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Death -.. irate Filed D�ctt Number Ister Number
Ci , Town • Village Uj v t /03 Q
❑Burial Date Cemetery r Crematomi �/ ,/Z 1 cr. ft%,,J
❑Entombment Address
remation t..W166‘-`i Q OW? Ci c,l✓t�-� ,.y /Z�
Date Place RemovedEn / /
Removal and/or Held
and/or Address
Hold
5-3
Date Point of
IX
Q Transportation Shipment
ri by Common Destination
Carrier
Q Disinterment Date Cemetery Address
s : Q Reinterment Date Cemetery Address
Siii Permit Issued to Registration Number
Name of Funeral Home 140,yna.r8 , Piker Funereal (wt-- 01 I 30 _
Address , Ni e v.:s yce IL 12 4 O It
� Q�0.y sZ{-�e- S-`. Q t�Lee.nS1o��.r`/
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Uit
Permission is hereby granted to dispose of the human emains described above as indicated.
', Date Issue l eo strar of Vital Statistics 0 ,
(signature)
District Numbe Place�— • „....._
___.
i I certify that the remains of the decedent identified above were disposed of in accord.- this permit on:
Date of Disposition " �0 Loci Place of Disposition -P,.itJ (,r v,c ar),.......
I (address)
Iii
fin
CC (section) (lotnumber)c (grave number)
0 Name of Sexton or P on in Charge Premises (Itc:1-111,- �t""/'tt(please print)
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SignatureAll Title Giw(>gcYZ
(over)
DOH-1555 (02/2004)