Williams, Frances NEW YORK STATE DEPARTMENT OF HEALTH 1 It 19 1,
Vital Records Section Burial - Transit Permit
111 Name Firs Mjddle 1 Last - Sex
---CC.x.`\ CS..S L-a W \ 1\ \ A MS re_rn CK\R.
giiiiiii Date of Death Age If Veteran of U.S. Armed Forces,
in OS - l 1 - 3.0 i G s War or Dams
Place of Death Hospital,institution or
-Sits, Town or Wage Lci \ z_.QX r P,_ Street Address ��.P,( St.
Manner of Death❑Natural Cause Accident Homicide Suicide Undetermined n Pending
Circumstances Investigation
il Medical Certifier Nam Title
0 c..;a.L 11,-,,,E.,.A.,,,,,
Address
3767 /1�..` S-1 l,-J1rr._,L,.0 j,J. Y I agg.S
Deat - - -- . ate Filed 6istrict Number U' Register Number
iel City, T•wn or illage i- 4 Lam-�� 5-6 _(.5
Date Cemetery or Crematory
❑Burial / a.�f a o r 3 •
ile v:�.. / �-�.:
Address A �
NI Cremation 0��� , ,,, N t.:� `r,r�
gDate -3 ) Place Removed
0❑Removal and/or Held
I`= and/or Address
a Hold
0 Date Point of
5 0 Transportation Shipment
a by Common Destination
Carrier •
:: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiiiiii Permit Issued to ; Registration Number
< y
Name of Funeral Home Q.__y,,c-,rY-,30._ unux u-1 u`M`� 00 `Pi c(
'3 Address 7 kz.rC�Y\ Uv Cox- \,-,,,-L 'i\i ,Z R,.
si Name of Funeral Firm Making Disposition or to Whom
:* Remains are Shipped, If Other than Above
Address
3 Permission is hereby granted to dispose of the human re ai s described above s 'ndicated.
's< Date Issued S-- ‘Cl - ,J0 I3 Registrar of Vital Statistics �� i(2, c.�A..J) 0,( ,'
'' (signa re)
Iir-, L
'` District Number 5c�s S��' Place L �U ZZr In (K.) V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.Ili �
Date of Disposition 5 Q7/-/3 Place of Disposition O?N4 (.4011 €i 7'Y
a (address)
iu
Cl) (section) , ; ` t number) _ (grave number)
0 Name of Sexton er n in e of Premises T-f- QrA/��►',
(please print)
44 Title CA11,t 44X A
Signature �'n� �'
(over)
DOH-1555 (9/98)