Morris, Betth NEW YORK STATE DEPARTMENT OF HEALTH 70
Vital Records Section Burial - Transit Permit
Name Firs Middle /' L ;fin , _ Last Se
V w'l
Date of Death AA If Veteran of U.S. Armed Forces,
- y- 701 3 , -7 War or Dates )1...6
N Place of Death - Hospital, Institution or
W City, Town or Village �JrJ . Street Addresso `�/• ✓� e `ems_
p Manner of Death al Natural ause Accident Homicide �
Suicide Undetermined Pending
Ui ` Circumstances Investigation
W Medical Certifier Name Title
c ai y Cif-4, 'PA 0
Address 1 t 6(. i i,_r ci/J4, n y rim
Death Certificate Filed ` District Number Register Number
City, Town or Village S (p 0
`< ❑Burial Date Cemetery or Crematory 0 Entombment 5 11 - !3 0 'v\'P t)``6W t t 6144-�.
Address[ Cremation c 1/ _
Date Place RerrtlDved
ZRemoval and/or Held
9.❑and/or Address
i" Hold
Cl)
O Date Point of
cnCL Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to I' 1 , Registration Number
W
Name of Funeral Home i- - c i 01 a /
Address
et-0, Ci. n,v i Z $
Name of Funeral Firm Making Dispositiorijor to Whom
iiio Remains are Shipped, If Other than Above
;'; Address
C
Ui
` Permission is hereby granted to dispose of the human remains described ab a as indicated.
Date Issued 5 -1 -,)01 7 Registrar of Vital Statistics As.)G/t,- Y 1 --
(signature
District Number 5-0 S-� Place V Lo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI
'C
Date of Disposition �'0�'�� Place of Disposition aw rvv-c10 f 04—,
(address)
Ui
CC (section) (lot number) (grave number)
its Name of Sexton or Perso in Charge of Premises r,Sj O„r./i1T
I (please print)
• Signature I ..,, Title C►t>r,,viqpit,
(over)
DOH-1555 (02/2004)