Vanderwarker, Anne NEW YORK STATE DEPARTMENT OF HEALTI-io I /
Vital Records Section Burial - Transit a ermit
Name F//i�rr t /' Middle ' � Last rSSeex
Date of ath Age , If Veteran of U.S. Armed Forces,
e/J �?t9-j ?--- 7 " War or Dates
}� P . - of Death Hospital, Institution o /,'/ 7/
6 own or Village a% r /,(r Street Address �.f //, ,�� / i
til
• anner of Death Undetermined P ding
S-Pdatural Cause Accident [l Homicide ]Suicide
Circumstances Investigation
at▪ Medical Certifier � %''�,
Name Title
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AOdLess ,A)eetie--/r2r,17.v. f /L0 Rc
Death Certificate Filed ,� District Numbers Register Number
Miii i `Town or Village. �f o- �' / - //r , l��� �
Burial Date or CrematoryII /D
]Entombment a/`57.471- )-- eegiTt s -;-- l.�'j�P i e ( /2.P"2-7 cl747,06,i--ki
Address /Y7
premation "P.✓L7 -/e;/C/1 ._../CZY 1 fl) `/ •
Date / Place Removed
Removal and/or Held
R.,❑and/or
Address
Hold
0 Date Point of
65 El Transportation Shipment
G by Common Destination
Ni Carrier
Q Disinterment Date Cemetery Address
iiiiiiiEl Reinterment Date Cemetery Address
PermitameIssued to /?jj' , — \ �� �1 rRegistrationNumber
< Name of Funeral Ho � C', of
Address
//;19 L..C7- -1-X7-i----"Af:-- 1 L=2c-c. 1G-7 „-- e-!/_. /W./7
NgilName bf Fdneral Firm Making p Dis osition or to Whom
Remains are Shipped, If Other than Above
Address
a
Ali
`` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued &1 `1 1 / )2 Registrar of Vital Statistics
CA 0 (signature)
District Number 5 12(), 1 Place 6 �NjS co, 1 1 S J �\1 I zcib \
I certify that the remains of the decedent identified above were disposed of in (accordance with this permit on:
. ill Date of Disposition 9'4-1Z Place of Disposition • T :4/0
t.,./ toru_
(address)
iii
C
CC (section) (lot number (grave number)
• Name of Sexton or Person in Charg of Premises Awi'�-
0
j« (please print)
Of
si Signature iii-
�' Title CM,ArrZc)(L
(over)
DOH-1555 (02/2004)