Smith, Audrey i 3 LI 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section , , Burial - Transit Permit
Name First I /
% Mid, i ct ask Sex
Date of Death Age If Veteran of U.S. Armed Forces,
OCAZ/ZO' 75— War or Dates
I., : of Death ` Hospital, Institution or ///
City, wn or Village Street r Street Address
< �� /
nner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
111 Circumstances Investigation
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Medical Certifier Name /� Title /,
CI ,�/1,1IiC•/ G1/',�, / r,d
Address 700 Ail L &' / A/Z
Death Certificate Filed t / District Number��O� Register Number
City, Town or Village (� / J 4, Ye-- •
• ' ❑Burial Date 06 /;2/20/3 Cemetery,C��Crema/tgry f
['Entombment
�/ I ' '/•� I/1 „h1 �/�?,14Ax
Address• /
Cremation • Uee J- -" /, AY
Date Place Removed
Removal and/or Held
.,.� and/or Address
E Hold
i
0 Date Point of
05❑Transportation Shipment
G't by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date •
Cemetery Address
Permit Issued to ,l�I l� Registration Number
Name of Funeral Home /�</9 yiil/►2� �, �U,�J[ �� l Jv' 4 l/3 d
Address
`/ Z-A�fa>(�44 5 ) vee,' - 6vrz y, N)`
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
2 Address
I •
w •
Permission is hereby granted to dispose of the human remains des iibed boo as ' d' ,ted.
Date Issued � r/ �iL "Q�o/l�/3 Registrar of Vital Statistics -
(signature)
District Number 5'60/ Place a/ o A A, iul
,.....: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
at Date of Disposition i„1 pi ir5 Place of Disposition 4?. t. ,r i Lto{i„� '
ILI
(address)
V
CC (section) I (lot umber) # (grave number)
0
Name of Sexton or Pe son in Charge of Premises p/fr 3/..al
2 (p ase print)
Ut
Signature L / - Title CIZ 190(
(over)
DOH-1555 (02/2004) •