Smith, Trisha NEW YORK STATE DEPARTMENT OF HEALTH " ���
Vital Records Section Burial - Transit Permit
Name First. Middle Las Sex
Tr i5hc, J Te ail rn)�-I- Rana le
Date of Death Age If Veteran of U.S. Armed Forces,
ULJ I ,cl 70/3 33 War or Dates --
I. Place of Death � Hospital, Institution or
ii t
City, Town or Village bron Street Address 31 - ; {.:1 0 F .
Ct Manner of Death❑Natural Cause El Accident 0 Homicide .Suicide ElUndetermined c7f Pending
1.0 Circumstances Investigation
W Medical Certifier Name Title
P. :5CPAC-5 . Garept 1/ LO(®rZf
Address
\et £4S+ ro cAtdow.� Sa\?Am N(-(, 1ZB"L5 .
Death Certificate Filed Distri Num er Register umber
City, Town or Village fi� .PO,1 Z/-CQO
0Burial Date Li Cemetery or ematory
[]Entombment I? Z + 11\k, V,2 pt.) e e it -O rut
Address
Cremation 1
Date Place Removed
Z Removal and/or Held
❑and/or
I:: Hold
Hold
0 Date Point of
114 Transportation Shipment •
Q by Common Destination •
Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Ria norr , ,a.br run,rr.I 3Y)LiL. 011 .30
Address
La F.-cake I-I-e. C t,re,e to bu rzi i N 128"0 4
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
ttU .
L1 Permission is hereby granted to dispose of the human re ins de cribed above as indicated.
11 Date issued ,22 / registrar of Vita;Statistics c71+'
(signature)
District Number 36 Q Place . /J 2d fit/
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z lL
Date of Disposition 11-7 .3 Place of Disposition � � Cerra torlw"-
(address)
ill
cc (section) / 4 (lot number) (grave number)
ci Name of Sexton or Pers n in Charge of remises G r, r SBrinr>
(please print)
Signature Title CeCe4')4 OVt
(over)
DOH-1555 (02/2004)