Parmelee, Jeanette NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First-•� I ( _ Middle L ram/7e��� Sex
j.i
, �(l�e,tt�. & Last -
r��Y�
Date of Death Age If Veteran of U.S. Armed For y�
9/2.6 /3 �73 War or Dates 1 tT-
Piece th tieeliatelT4RefitiotieweFZ 2 cobble5fon-e.
City, DVillage Q(.13bU Street Address r.
Manner Of aturai Cause Accident El Homicide El Suicide ri Undetermined nPending
Circumstances Investigation
Medical Certifier Name Title
1 c /91 C/L Lrii(,vL,.._
Address
t we
,,.
0/er-->s F0-1, s ' s P9 r 7
:Ai Death �cate Filed n District Number R ist r Number
r City r V'diale &ue .5 (Arts fi(Dc Q
Date Cemetery Crematoryp
S ❑Burial 7 Z7 /3 A.) cc UO 6--
Address
emation
Date Place Removed
g pi❑Removal and/or Held
and/or Addrs-
a Hold
0 Date Point of
I0 Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
••:ii D Reinterment Date Cemetery Address
4 Permit Issued to Registration Number
Name of Funeral Home Maynard b. cctker Finerc�/ Homes o(i 3C3
y Address // I- 1-C yR#e of. / b uee nSbUnd , AAA-0 I/041- l g 80 /
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
-' Address
v• Permissi is hereb granted to dispose of the human remains described above as indicated.
Date Issued-Alf-Z.'? � Registrar of Vital Statistics+CL_ rt- n--r--.,.
(sign re)
• District Numbec` Place L Q cam.,--, � lA.9Sz-r‘C
I certify that the remains of the decedent identified above were disposed of in dance with this permit on:
1 Date of Disposition 4130113 Place of Disposition l,"tUu`' �+'r'r..
(address)
III
IA
(section) t.number) (' (grave number)
'D Name of Sexton or Person in C arge of Premises '► r..tl
Signature LP1ea5nmfl
Title Cefoltirot
(over)
DOH-1555 (9/98)