Waite, Mildred NEW YORK STATE DEPARTMENT OF HEAL 1H 4 4 5 S7
Vital Records Section Burial - Transit Permit
Name Firs Middle Last ex
Date of eat Age If Veteran of U.S. Armed Forces,
i� 1 ap i
War or Dates N o
- Place o Deat Hospital, Institution or W City ow or Village -}-)CAL) I6.1 Street Address SS& rc/Ci R /
a Manner of Death fi7'i Natural Cause ❑Accident ❑Homicide ❑Suicide El undetermined ❑Pending
Uj
0 4� Circumstances Investigation
W Medical Certifier 4m, Title
O n P-t )-1- C CA ;Trr , NO
Address /NN
Glens r-ails,
Death Certificate Filed Distri t Nu ber Re ister Number
City, ow or Village +lad 16 ,.5 S
0 Burial Date 1 C tery or Crematoryy
❑Entombment c o - ( R r' o� / L r Lj P 0...reif YEA L
Addres \
}®Cremation ,sbu n7j ivy )a i O
Date Place Rem ved
Z ❑Removal and/or Held
9. and/or Address
�=" Hold
til
0 Date Point of
tiL
❑Transportation Shipment
a by Common Destination
ilN Carrier
El Disinterment Date Cemetery Address
.ii ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
I' Name of Funeral Home B 1 Wg, Eu4(A[, fI (II
Address
2,tA akke H g- 09-kit LOZ&r 4. I 711G
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
Cr
la
Permission is hereby ranted to dispose of the human remains described above as u,dicated.
Date Issued /0 jc)- Registrar of Vital Statistics ,i< 1.4_4_,_,..t.si. '` "ii
111 (signature)
`< District Number y 55 Kj Place 70n of l/a d ey
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition i'0°-27rt`L Place of Disposition ZAA.(.,) �reArktor+vr.
a. (address)
LLE
CC (section) (lot number (grave number)
Name of Sexton or Pe son in Charge of P mises itr>riu 3�-n'�*'J(�
Z 'ilk
print)
ILI
Title r' E'fthi t)✓L
Signature
(over)
DOH-1555 (02/2004)