Sheldon, Charlean NEW YORK STATE DEPARTMENT OF HEALTH - '11, 5s---
Vital Records Section Burial - Transit Permit
Name First ,; �r��a� Middle Last ss\a ( 0 I Sex
Date of Deat Age If Veteran of U.S. Armed Forces,`(
11 � � o�� 1 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village �y \f f Street Address
Manner of Death Natura`f ause 0 Accident 0 Homicide IEI Suicide riUndetermined Pending
Circumstances Investigation
ktiMedical Certifier Name EE' C �s �� Title
I 2 (� �(u Q l
Address \00 cCl6- — GIe\AS �� t 1 ( \2Uc 1
Death Certificate Filed District Number 5-750 Register Number
iiiiiil City, Town or Village
El Date 2 Ceme ry or ematory
Burial /25 /Zo1 J TI e\AJ C.iMCiA-O`f/Address
M Cremation I Q c ;-e r tad Qu,eeevis loi- ( / / / 12 o q
Date Place Removed
0 1--1
Removal and/or Held
••• and/or Address
Hold
O Date Point of
u)Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
i Name of Funeral Home 1\1(\. . \C,\v vec \I-owl-E._
ye rot 1 0101-7
Address
11 V2-I V1C,Ct a SA- 6, N-/ IZeo
9 p
i,..._.: :::::: Name of Funeral Firm Makin Dis position or to hom
Remains are Shipped, If Other than Above
2 Address
W
ii
>: Permission is mere 'y granted to dispose of the human re ains described above as indicated.
"' Date Issued !fZA i'5 Registrar of Vital Statistics i Lf/1 Lle`s y
ignature)
III District Number 5150 Place Nlibqlk (4{
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- i f ,
Date of Disposition (- .-'� Place of Disposition -R,,,do,w C LNHit_
(address)
14
CD
CC (section) 1 (lot number)csmwti, (grave number)
GName of Sexton or Person in Charg of Premises As,► pt....
Z ill,
(please print)
Lt4 Signature . Title GE wltnDt,
DOH-1555 (10/89) p. 1 of 2 VS-61