Lang, Dorothy It 3
NEW YORK STATE DEPARTMENT OF HEALTH . ��
Vital Records Section �' Burial - Transit Permit
N First Middle La n Last ex
Ki':' ,1) rThf-hYDate o Deat Age If Veteranf U.S. Armed Forces,
LO - 1 -an 13 ...J.J... ' War or Dates 2__
a Place of Death i Hospital, Institution or
Citygii-wn pr Village jp h fl,5.��(.,c_t— Street Address
Manner Of Death fill Natural Cause QAccident Homicide Suicide Undetermined Pending
�'�J Circumstances Investigation
•
Medical Certifier Namme`�Q� ( Title
r (1,_ . t M V
Death Certificate FiI District Number ` Register Number
-..� g be
City ow or Villag C rh n u , S-6,5
Date _ etery or remato f
❑Burial —__� -5- p�Q t�j 1 L) 1 __.
Address (,-
14 Cremation I (_ Ice d
Y
Date Place S emoved
0❑Removal _ _ __ • and/or Held
and/or Address
N Hold
0 ' Date Point of
NQ Transportation _ Shipment
is by Common Destination
Carrier
Disinterment Date Cemetery Address
i
Reinterment Date , Cemetery Address
'' Permit Issued to I Registration Number
Name of Funeral Home1J i 1 te.,r ,.Yael111____, C I 1 _!C3
Address
::F'::. gif---___a) _i__Odlaa. L2_..f .,.....m_y_12
Name of Funeral Firm Mak Disposition or to Whom
g
Remains are Shipped. If Other than Above
t Address
ILI
Permission is hereby granted to dispose of the human rem 'ns described ab as indicated.
Date Issued v 6l1 Registrar c.
0 1f l3 of Vital Statistics - � - .,_
(signature)
s District Number cS(o 5 Place l D(gill d ?�/1_ i7 1 �j S __
I certify that the remains of the decedent identified above were disposed of i accordance with this permit on:
Date of Disposition G-G'13 Place of Disposition ,,j ccv loru-.._
2 (address)
W
Cl)
CC (section) (lot n tuber) (grave number)
dName of Sexton or Person in C arge of Premi r w
(please print)
414 Signature lq., Title C1)1117qte
DOH-1555 (10/89) p. 1 of 2 VS-61