Anderson, Connie IT Zo
NEW YORK STATE DEPARTMENT OF HEALTH • - • " •
Vital Records Section Burial - Transit Permit
iiiA Nanyer First fiddle Last
CJ C�(� ._k \, O/SCE n S
<`3 Date
of Dtl� a Age If Veteran of U.S.Armed Forces, .
I? 1 ( r a L.e. 0 War or Dates
14 Place . '-ath Hospital. Institution or
Z City • . Villag Street Address CD LV 2fKQ (cx d
NMan - • i eath atural Cause cidentUndetermined Pending
I �Homicide Q Suicide � �
Circumstances Investigation
Medical Certifier Name itl r
c� IC in , fry- 11 1,tj
Death C rtificate Filed Dis t Nu ber egist Number
. l. 0 -�c-c.,,,Hs I ago(
egist
C' `Town o�r Village \-16
Date OJ Cemetery or Crematory .
:=: ❑Burial j/ ViRC4 I hlE U, Lv c rii9 7-0 RIO In
Address •
: &Cremation '� 7V-S' (a GrA X/ A/y,
Date Place Removed
❑Removal • and/or Held
and/or Address
Hold
0 Date Point of
0 Transportation Shipment
L? by Common Destination
Carrier •
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Num r
. iiiq Name of Funeral Home m)9s OAf Fit J/&R)L- ,44ii- J t el / / /
EgA Addressr., / �}h�H /\ 1e .
���:< Name of Funeral Firm Making Dis osition or to Whom •
"' Remains are Shipped, If Other than Above
Address •
la
tit Permission is hereby granted to dispose of the human remains described.,above as indicated.
><, Date Issued 1 c\ 1a,01(:) Registrar of Vital Statistics"_ CS).... n,t�:�,
ignature)
I District NumbeeL )c--) Place 1 LA--,--.. 4--
I certify that the remains of the decedent identified alcove were disposed of in a rda ce with this permit on:
f4 i
: Date of Disposition ►/1U lit Place of Disposition gv2Urr� C :1or�,v1
(address)
(i)
X (section) q (lotnumber) (grave number)
GName of Sexton or Person in Charge o remises / (Al tivi
Z /1 (please print)
4t SignatureliL.. Title CV ginA-iat
(over)
DOH-1555 (9/98)