Sweet, Laura NEW YORK STATE DEPARTMENT OF HEALTH -* n 7
Vital Records Section Burial - Transit Permit
Name First c-. MidOe st Se�
�a---G1 ��/.� J/ J
Datq of �h�� A29� If Veteran of U.S. Armed Forces,
`J War or Dates
1.- Place.- _II- th f� Hospital, Institution r
z City. Town ,i r Village T ,4 c��✓.,,. ,3/ Street Address //� � Sto�u-/� �Y1lievn-e
p Mann- of Death Accident H Homicide a Suicide Undeterfnined Pending
atural Cause �A ci �Ho i d � i
LU J Circumstances Investigation
W Medical Certifier Name Title b( S C!0.t�
c front ti�� ) fa/2 t"`'1 y
9 Ad s
Dea rficated /�
/Q Distr u/mber��
Register Nu ber
Ci Tow or Village /7) � �)d j 7
ElBurial Date Cem ery or Cr tory
[]Entombment ` c '� /f U `O'iA, OA mGT
A res
remation U_, Q_� /7)v
Date " Place Removed
Z Removal and/or Held
2❑and/or Address
N Hold
0 Date Point of
6 Q Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
__ Permit Issued to "yrictiC Registration Number
Name of Funeral Home c ,D. &. _3a'_ A it 1S ZA,4 0//JA0
Address
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Name of FuneraF-Firm Making Disposition or to Whom
I_— Remains are Shipped, If Other than Above
g Address
CC
n` Permission is h reb granted to dispose of the human ains described above s indicated.
Date Issued / Registrar of Vital Statisti
/ (signature)
District Number 5 7� �r�Place Ci kc.---// %vtC
I certify that the remains of the decedent identified a ve were disposed of in accordance with this permit on:
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Date of Disposition I-1-13 Place of Disposition ,i1 �t l rw.
2 (address)
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LC (section) y (lot number) (grave number)
Name of Sexton or Person in Charge of P emises /It:a -lm,,ft
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Signature Title are1410(f_.
(over)
DOH-1555 (02/2004)