Boyer, Patricia NEW YORK STATE DEPARTMENT OF HEALTH # II
Vital Records Section Burial - Transit Permit
Name Fi st Middle Last Sex
Date of Death Age If Veteran of U.S. Arrrrfd Forces,
ligil mGP/!/CI a‘ 2 012_. 7'/ War or Dates Al 0
Place of Death / Hospital, Institution or
. City, Town or /i a Street Address
ct 4
Manner of Death f�Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
iii L.i Medical Certifi2c Name Ce , Title
6
Iiiiig Address
)/, /2? ‘'.i
Death Certifi to Filed strict Nu A� Register Number
Ei City, Town ore let
iL
❑Burial i. e'' � � C etgry or Crematory
❑Entombment 1 G��Z " ( '2®(Z (/�'11LjJ'I1�GtJ
Address
NtCremation a n
Date Place Removed
Z ni❑Removal and/or Held
2. and/or Address
Hold
5 Date Point of
toiCi ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date • Cemetery Address
❑Reinterment Date Cemetery Address
PermitpiiI Issued to R C i:T!Ji c Regisigti90 Number
mi Nameameof Funeral Home
mi Address
Ni
36 4M1Kle6-v Si �letis / '/s Al/ 4)&01
lip N me of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
Address
1
LI/
m` Permission is hereby granted to dispose of the human remains described above as indicated.
il Date Issued 3 -Al. /04 Registrar of Vital StatisticsA -r- -- �zj < - _—
(signature)
District Number `?17,.., Place ' ,......j11).0 <5ri ! ,,___'t
,..;.:: I certify that the remains of the decedent identified abo i were disposed of in accordance with this permit on:
W. Date of Disposition 1-21-`'L Place of Disposition P1,.4 Um.) C nnfrc GPit`
(address)
to
ce (section) (lot number) (grave number)
/1 r
Name of Sexton or Person in Charge , Premises L ^'AaPi r- J iN�kt
'� ('please print)S14 ignature Atli., Title �rZW1 to
(over)
DOH-1555 (02/2004)