Humme, Cynthia r
A �� 01,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
3 Nam First Middle Last Sex
.-- Fn►a%
Date of Death Age If Veteran of U.S. Armed Forces.
a ).2 -a .-.2 o la -is __�_ War or Dates no
f`" Place of Death Hospital, Institution or
City(Tow)or Village ex.n Sb�,tw Street Address 8 Meadow t r.
'Manner of Death Undetermined Pending
d (�Naturai Cause � ccident �]Homicide (�Suicide �] �
Circumstances Investigation
Medical Certifier Name ` �, Title
0 _ r ob�.i---� t Vl r t`.e r J , cs
Address
1\ji5 (Ka vlknc& N
, Death Certificate Filed j DiViot Number i Register Number
• City, owp r Village Gueg,n SbU i c c m ' i (I d
Date metery or Crematory
❑Burial ; (al ) 11a., \i,et�)
Address:--, -�_________
gCremationl t.L_�_ i TL
��Date ^JN + Place Removed
O❑Removal ' and/or Held
and/or Address
CO Hold
O ` Date Point of
Q Transportation '= Shipment
G by Common Destination
Carrier _
Disinterment 1 Date Cemetery Address
•
Renterment ! Date ; Cemetery Address
. El
', Permit Issued to Registration Number
Name of Funeral Home ' '\L z-v( -I Tvn Q ) n L 06D 1 1
Address a'T Chw�K S L c.. Luz-e-r-r 2 a�
Name of Funeral Firm Making Disposition or to Whom
P. Remains are Shipped. If Other than Above
Address
Permission is hereby granted to dispose of the human r mains described a 1.ve as indicated.
Date Issued lc�-)�. pja Registrar of Vitai Statistics _ l ►�.t�.�
(signature)
District Number c S. Place 0 1-,--,--, �LA—C-¢rv;
I certify that the remains of the decedent identified above were disposed of in accordanc it thi permit on:
1r-
WDate of Disposition [-t{-t3 Place of Disposition Zi,Vir,a
2 (address)
W
(I,
m (section) ,/ - (lot numbej) (grave number)
GName of Sexton or Person in Charge of Premises AO L-- Jthnit"
Z (please print) 1
W Signature /4 ,i-- Title C(t&1, Tot
DOH-1555 (10/89) p. 1 of 2 VS-61