Streeter, Andrea if TL3
NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
``''< Name First MiddleLast Sex
�nJ A Q 619- �6 (ThT7 E L 6)'L / 6-17 e--- c_r
Date of Age If Veteran of U.S.Armed Farces,
ei �'' 2tf-/!_.? &,1- War or Dates V- `
- of Death on or hi-/7 b't.) `to own or Village UL1 r;S /S -u StreetAddress J7 i2(� r frE7-7c
j O t-J 6i.5
of Natural Cause Accident Homicide D Suicide undetermined Pending-�
,, �� � Circumstances Investigation
Medical Certifier Name Title elk E Ai A= Sp ,Ive 11, M.s. 4N
Addr r�
:. • 1 — & .CT S((,rL e Z IN mast r I2-c!1
•-.:,+ Certificate Filed _ District Number Register Number
`g City, ° own or Village UL(�it.Ls J-g'u-s 01 3-1D
, ■Burial Date ?,�, Cemetery Crematory:„1s„„1,„,i,: 6i�=liJ A) a„__,-.)
tion
1 E C mtv atn t Address /'N_ a t. C Q 0 -?� uv - r A f�
Date ( Place Removed / i l
..� Removal 1and/orHeld
= and/or Address
- Hold
14 Date ( Point of
b0 Transportation 4 Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ifS Permit Issued to ,a ` , Registration Number
:: Name of Funeral Home 1-`a1nw 4 'D` esker riA_nerc.I t'1C3t71C p i ti 3p
==A Address i V La-Faye-1-4 e- Si-reef)
Queellsbt..I..ry , New. Vol- k. 1'0l Sot-4
`:<' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
l
5
tt Permission is hereby ranted to dispose of the hum remai s descri above as i dice ..
gg
gt Date Issued ` Registrar of Vital Statistics 6C� ,�J �
pw (signature)
<' District Number / Place A Z `79 L f p2 I
Vie:t I certify that the remains of the decedent identified above were disposed of in acccordanc - this permit on:
Date of Disposition U 9 7/S Place of Disposition /)./v1 vje.„,.., 4444r, ie
(a )
iii
Ca
(soon) fe �Xmb (grave number)
et Name of Sexton g(- i• i) • of Premises ✓�D d
1
I. I0i� .�/ I Title 0,4 4dcPlease ,7
_ Signature ,, '
(over)
DOH-1555(02/2004)