Ladd, Jayne , 1Ic
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per It
Name First �a i1R_ Middle / Lust, Sex
Date of Death Age If Veteran of U.S. Armed Forces, .....—
'i j 013 5�S War or Dates
Plac r,f heath Witt/ I 1pital.anotttution or RUC"
Q t�Qs2.r)s . _ Gtreet Addr 6)9 Q {
p Manner of Deatly� Natural Cause ^Accident n Homicide n Suicide C Undetermined n Pending
iY'` Circumstances Investigation
W Medical Certifier Narne Dr.
Mom'' Title
Address Q Q rLoct s+. , G S j cuttS A A A / 1Q'S D 1
Death Certificate Filed i,-, District Number 1 Register Numbefr
- - own , •• ..- �f 7 S
Date - Crematory
❑Burial L�� a®l3 A/1.� VLu.J Cie a ..-k
❑Entombment �
N►_Cr matron Address C _/' / u winsy„ - A , ,, 1 I 3 \1 !, 1D CY-1
Date Place Removed
Z n Removal and/or Held
and or Address
— F-old
N
0 Date Point of
N [Transportation Shipment
a bi Common Destination
Carrier
ri Disinterment Date Cemetery Address
Reinter ment
Date Cemetery Address
Permit Issued to - ) 1 Registration Number
1(a\li�C0 '- i l0( l� a
NamF of Funeral Home t t_)( , ` I ( ,,}. _-� I I ';t
Address r
'1 1; A (I t ,A i f r i ( i , ,( ( 1 1 I )( i I y P It
)` I ; ' ( i )
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped. If Other than Above
2 Address
CC
w
O. Permission is hereby granted to dispose of the human remai s described above s indicated.
Dat Issued y- 5-_ ✓,? Registrar of Vital Statistics , CL, �L ))
(signatur
District Number Place f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /,
W Date of Disposition 14-$-r) Place of Disposition 2/1/tio (_ CewA--
g. (address)
W
U)
CC (section) (lot number) (grave number)
p111 Nam of Sexton or Perso. in Charge; f Premises r�l � -
Z (please print)
W Signature (_' Title C_ % t1_ �`,t,__-
(over)
DOH-1555 (02 2004)