Williams, Carol NEW YORK STATE DEPARTMENT OF HEALTH y r
Vital Records Section Burial - Transi Permit
tg Name First Middle
' (aro\ Pylrl Last i 1 I t wan 5 Sex
Date of Death Z Z1 , Age If Veteran of U.S. Armed Forces,
3 VI War or Dates N 1 A-
. ce of Death Hospital, Institution or
} own or Village C"j n j PA`k S Street Address 61,015 0.1\ v4 os +c�
`x Manner of Death f Natural Cause DAccident Ell Homicide 0 Suicide El Undetermined �Pending
• Circumstances Investigation
e Medical Certifier Name Title
(Y1C j \jafix iej-e. M D
Address
4 \DO car1C- SI'r -A- 31-enS C4.1I5 .0' 1z OJ
D-- h Certificate Filed District Number _ Register Number
:.•.. ,Town or Ville fps C{‘1s ! o
566
r—t Date I Cemetery or Crematory
QBurial 12-L 2`11 2.,013 f;Y\.t.. U t1,3 cMei 1-Uri
Address
: I Cremation t os k)(An/i A) )2-gb7 c
: Date Place Removed
a❑Removal and/or Held
and/or Address _- __
ii Hold
.d Date Point of
Q Transportation Shipment
a-{ by Common Destination
Carrier
El Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
r Permit Issued to Registration Number
!�l ay
nand O. a-/ /-fume.
QI I3
k<, er Funer t�
•,,� Name of Funeral Home
:' Address /I La a L C e of. 6 Sbu L r
New /v k 1 a ivy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
•
,' Address
IPermission is hereby granted to dispose of the human remains described above,as indicated.
• Date Issued 12.1 2-7 If ; Registrar of Vital Statistics 1J�1 .,\A)a^"- ✓S?
:; (signature)
District Number 5 J ( Place 6 (:,Z c FU J \ 5 , t\t' )
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition R R-30-l3 Place of Disposition �,if,,, alK,,tek,`
(address)
i
"' (section) (lot Om; (grave number)
•: Name of Sexton or Person in C ge of Pr ises r,, r Ju i4
(please print) ill
Signature Title C+7/t; /Z,
(over)
DOH-1555 (9/98)