Winters, Bernice it AO
NEW YORK STATE DEPARTMENT OF HE1 TH-04
Vital Records Section Burial - Transit Permit
Narpie .First Middle Last Sex
13 Q._Y'Cl\C e_- IA VIM i-SL Yr,S F
Dat of De th Age If Veteran of U.S. Armed Forces,
�` \ 6J War or Dates NJ 1 f)
i-- Plac of Death
Hospital, Institution or
City, Town or Village -,y VF\0,0,- � a �Street Address 1 c. L_ D leyr w" �ND
0 Manner of Death atural Cause El Accident ❑Homicide ❑Suicide ❑ Undermined Pending
%LiCircumstances Investigation
GMedical Certifier R Nape > Titl
Address
Death Certificate File District Number Register Nu
City, Town or Village'NC \ C•oA.-) v,3_9(1-- 1-4c-5L 3
El Burial Date❑ C metery or Cremato
E mbment IQ\ Cli,; _0 3 \v (L__\/ \� Vc_v iva--oY 1 OM
Address
Cremation v C L-Y k,c_CL\lam l.,l)Y- l
Date Place Removed
Removal and/or Held
2Z❑and/or
E;;� Address
LI Hold
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
•
Permit Issued to t Registration Number
Name of Funeral Home \ \\S( \Th r n' \v a\ 1\ C _Q._ ,� 1-V. On.s-,t—.3
Address ,�- r,‘ `
:.- i'-t_ \&', \\V,-- t-) -.- Th-'v , \Ai' \-1\ ---\ Q___\6- _\ NLi IQ ' ' ,5Sr-i
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Lu
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued \d Re istrar of Vital Statistics ,_ r
�`1 �C)1� g �� n��-k- � � ll u.)\_,F _,h,
(signature)
District Number 14-j Place'(15L, ` I \\\\\\
lE- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition la- 0-13 Place of Disposition ,,a V u,.,) �,.i,t�,�,
12 (address)
CO
CC (section) Il
(lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises - �-t "
lease print)
Signature10 Title CV 1A° 1L
(over)
DOH-1555 (02/2b04)