Miller, Harriet /t
NEW YORK STATE DEPARTMENT OF HEALTH 1 Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
tl !Z /- )I f / ofFr-f i,4 L
Date of Death / Age If Veteran of U.S. Armed Forces,
/\/erVL-� ,tj L-2 2 - Zc�13 6"3 War or Dates /v /►
}- Place of Death ' Hospital, Institution o
WCity, Town or Village LA k r-- f'LA c/D Street Address 3 j/ F-i/1.4__ /erkD 0/?.
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide r7Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
a FiA1 v G- L/Ckr-iAN /ti- 'Ill7
Address '
G✓L.- t 4 2 K sip r-/ - L i 2716 rryret,v /v/ 1 2 cj 6r 3
Death Certificate Filed District Number Register Number
City, Town or Village V/ • :(6 c�i 4_, /c 4" 15 Z 3
LIBurial ' Date ,"ci_k=,oi Cemetery or Crematory
❑Entombment Nos, 2 / 2L'73 h/N L- \ Pc N,v CCZC-.�-iA%en
Address
[Cremation 2/ A r,,�) 1c1__ri I-'D, f' v e-E-Na/ c.r / Ai y 12 dcry
Date Place Removed
Z Removal and/or Held
d❑andHold/or
Address
CA
0 Date Point of
inTransportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Iv) (j r c/_i n)- l N < <''; a 7S
Address
2 3 /Cf -i h/Z/4 A,/J L f V e LA 1L /el--/f el"/J /V/ % C 4j c/
Name of Funeral Firm Making Disposition or to Whom
lii Remains are Shipped, If Other than Above
2 Address
re
ttt-
CL
Permission is hereby granted to dispose of the human re 'ns de ribs/d abov re
as indicated.
Date Issued p i ' r 3 _ Registrar of Vital Statistics (irt/I Le S ti lC id e
/ (signat re)
District Number is--Z 3 Place i/, L A 4 4,,,F L/4/c (.7" /21-A c1/1)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ill Date of Disposition it-��i3 Place of Disposition
,.s!/ .,.t Crr,. ,�
2 (address)
1!1
VI
CC (section) t number) (grave number)
Name of Sexton or Perso •in Charge of remises i0° iiiNll
Z (plleas�print)
iii
II111Signature Title MCm4-1:r
(over)
DOH-1555 (02/2004)