Henderson, Norma NEW YORK STATE DEPARTMENT OF HEALTH ' '' 4 t 3V1
Vital Records Section Burial - Transit Permit
Name F�iirlstz 1y� iddlen Last Sexex
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Date of Death Age If Veteran of U.S. Armed Forces,
'7 --30" 20 1 3 49D War or Dates /4 o
1- Place of ath _. Hospital, Institution or
6 City ow r Village o/d-2,y.e-at r'l, Street Address/7 j4 Yon ROA,
a Manner of Death Natural Cause 0 Accident Homicide Suicide l Undetermined Pending
iiiCircumstances Investigation
U Medical Certifier Name Title
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Address
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Dea,k rtificate Filed Dislff
trct�Number AS �� Register Num er
City,\ i or Village rsYP G.. `��2 1
DBurial Date �7 Ceme ery or C�re�atory ��
DEntombment Address0✓ —,F/ 13 `%i°')G !�'t� t/ e✓h 6
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remation �kPa RAC a(,oPyl SZL i VP LW(
Date Place Re ed
❑Removal and/or Held
and/or Address
CO Hold
0 Date Point of
NQ Transportation Shipment
3 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Hal n .l`ci D. I3O Cr" I-L&.i€'C- I Hoy) C` 113Q
Address
11 Lc tc VE-i ^4c Sired ) QL.teerlSbury , New 'tor- 1c. 1d $(7ci
Name of Funeral Firm Making Disposition or to Whom
1I- Remains are Shipped, If Other than Above
2 Address
tZ
I I
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7 j30/V/.5 Registrar of Vital Statistics / 4 tt Q f - --
(signature)
District Number )/!t, Place /4 -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1-3 i 13 Place of Disposition
4wi �Iv1-40r'w—
Ul (address)
VI
re (section) (I number (grave number)
ap Name of Sexton or Perso n Charge of emises ( Yi Srfi1en
Z please p nt)
Iii Signature Title OWE lIfib
(over)
DOH-1555 (02/2004)