Arney, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH - lit # (Z,
Vital Records Section Burial - Transit Permit
Name First _ Midd,otty tsaprE Sex
rig Date of Death%/ Age, If Veteran of UArmed F6rces,
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O War or Dates
Place of Death / Hospital, Institution or /
City, Town or Village 6 S 1 Street Address 6-1-EL)-) "'fit-c-S /X SP7'A
1 Manner of Death p1atural Cause ElAccident Homicide 0Suicide �Undetermined Q Pending
Circumstances Investigation
Medical Certifier Name /9 4 L /LL/M Title l,- 8
Address
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Death Certificate Filed District Number I Register"�' r
pit City,Town or Village S6 0
%-', ❑Burial Date tery or Crematory
- 3/S-426/� .6(1it:ti, C:-,Q.5/`9.4— ;u.
❑Er�mbment Address
:,Cremation 02` Qic4-)& ;S re • U '8 012 y /1/y dF
Date Place Removed
ID Removal and/or Held
for Address
iii Hold
0 Date Point of
0 Transportation Shipment
co by Common Destination
- Carrier
<<`Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
!. Permit Issued to , Registration Number
Name of Funeral Home ,p,4�A- t/,! oJC_ ill o,73—
Address/3 6' c,`/911.P .1 6.< r -s /1 4/ /o?,OPe /
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
to
Permission is hereby ranted to dispose of the human remains d bqd ve icated.
gii Date Issued D/0V/2 Registrar of Vital Statistics �� G/��
(suture)
District Number 52/ Place �j� „Q A7t, m
"'" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k (�
U Date of Disposition yic.,,0(. 6 i tco'LPlace of Disposition X`����.cc+ C,/'' f rA-
(address)
tii
te
ii (section) i ' (lot number))� (grave number)
#3 Name of Sexton or Pers in Charge of P emises Zit-4'1111-r- -Ltt
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iii 4 Signature Title Citr, TetL
(over)
DOH-1555 (02/2004)