Parker, Deborah 4 cgil .
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit•
Vital Records Section
_"
%f Name First Mid e Las Sex "
Date of De h Age If Veteran of •S. Armed Forces,
�. �- . (o a o/3 �(¢ War or Dates
"l l Hospital, Institution or / �--�
e City, Tow eo Village 'Le -� Street Address CP G.e4s 4 11c ifD
'AK =-„ = of Death Undetermined nding
/) ,
� Natural Cause �Accident �Homicide �Suicide �
Circumstances — investigation
Medical Certifier Name ..._. - Title ,
/
Address �/'' i I
a;� . P4.1,/< Si'. (.94e,,,- -a-, t I /a�81
`'' Death Certificate Filed District Number 50Q Register Num r
City, Town or Village l `b
_ Date Cemetery or Crematory
___. Burial . c -6 . I a a 3 i-,,e_v:t_� 6C.K4+/
' Address
Cremation, A.e__QAS b r.l ��� ,,r-,
.3 Date / Place Removed
— Removal and/or Held
O and/or Address
Hold
O Date Point of
N -Transportation Shipment
v by Common Destination
Carrier
— Disinterment Date Cemetery Address
— Reinterment
Date Cemetery Address
Permit Issued to7_;_ �— Registration Number
yr; Name of Funeral Home `�—� ^c . 0 a `�`t-y
Address
! /- �2�-
St,,,,,... Av jn
'< : Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
0t
n
:i%
;. Permission Is hereby granted to dispose of the human remains describ above�s I� d.
Iiiii r Registrar of Vital Statistics A.Li jiL �� 1
Date Issued �I/9 f 3 9
(signature)
•Iii District Number J
GO Place (�1�it> -ills- Aj %°rC
I certify that the remains of the decedent identified above were disposed of in goadikkd
ccordance with this permit on:
Date of Disposition Ii1119 Place of Disposition C fer`..-
I,
2 (address)
w
(section) (lot number) (grave number)
0 Name of Sexton or Person ' Charge o Premises r, hio'
ci
Z (please print)
Signature Title Cn 9e3i.—
(over)
DOH-1555 (9/98)