Moore, Cheryl NEW YORK STATE DEPARTMENT OF HEALTH Perlt
Vital Records Section Burial - Transit s t
Name First l_. 6 e(- r Middle Le _ Last V\(xY- Sex F
mi Date of Death Age G If Veteran of U.S. Armed Forces, n
Z. 17 [ ) ,3 0 _ War or Dates )r*
ce of Death -os•" . stitution or 1
C own or Village �1eYIS C�1\S Street Address �a1�S iTCI
anner of Death "Natural Cause Accident Homicide Suicide Undetermined ending
�� Circumstances Investigation
Medical Certifier Name Title
Address
1 DO Plr\ S.\-' Cam Val\5 N j 1 -& 1
Death Certificate Filed District Number 1 Register ber
<< City, Town or Village (-11 C'"S c c \\ S ��
Date Cemetery oCre
El Burial 12. 1 1't ) -2.013 '\n2. \) ,evJ &pcooVary
Address
ElCremation «.een.SbAr, 1 N.)y
Date Place Removed
0 Removal and/or Held
and/or Address
gHold
Date Point of
Lif--1 Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
<':� Permit Issued to _ Registration Number
li Name of Funeral Home i :�:.91th )1, Atat f-v,.,&-Yu j4 is Q L 1 3c
Address P.7
,
1/ I- alP-% ¶ . 0 o .04.d 0 , / y
/ --o if
iP Name of Funeral Fm Making Disposition or to Whom -
Remains are Shipped, If Other than Above
Address
li
fa
Permission is he eby granted to dispose of the human remains des bed abov as indi,ated
1.1 Date Issued / a 0q �>3 Registrar of Vital Statistics /
(sign r
iiig District NumberO/ Place —
I certify that the remains of the decedent identified above were dis osed of in accordance w this permit on:
f-
W Date of Disposition 11' 1J-17 Place of Disposition -ri'()../ 6.,e406..-
2 (address)
LU
C (section) lot number (grave number)
0 Name of Sexton or Person -n Charge o Premises �rs `So,nrt(
Z (please print)
Signature Title Cf?E mPuQ
14
- (over)
DOH-1555 (9/98)