Vail, Elizabeth 1 It -1°)7,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Na r(� First Middl Last 11)cuth_.
Date of De Age I If Veteran of U.S. Armed Forces,
(�—3— 1 ,)- . '15 War or Dates -)A,p
i4 Place of Death j Hospital, Institution or
2 City(Thw'tor Village Street Address
iii
Manner oDeath N ural Cause Accident 0 Homicide 0 Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Ce rr_ Name Title
��
c. ►�P YI'&-a- Ld .k • _.
Add ess
Dea th Certificate Filed bistrict Register Number
<, Ci wn Village i 66 5 , a t
Date metery pr Crre tory
❑Burial go o 4,�Oi a-. v
Addre
El Cremation' ii� �A,.
Date Pla e Removed
t Removal and/or Held
O and/or r_. Address
Hold
Q Date Point of
N0 Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment I Date Cemetery Address
Permit Issued to �n Registration Number
Name of Funeral Home 1 9 1a i i y
Address
ce3J-7 S 3O g1IL a i I sirk �.
-.L.'.:. Name of Funeral Firm Making Disposition or to Whom
N Remains are Shipped. If Other than Above
Address
La
Permission is her y granted to dispose of the human remains dess/cc�ribeddaabo s indicated.
Date Issued �j l�) �d. Registrar of Vital Statistics (4. XY�t' C c �
si nature
f 9 )
District Number SG S�^ Place 1 k. \ -r . btt
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ( I( I11 Place of Disposition gi(*4I)uv CrfA f ofnuti
2 (address)
W
CC (section) f (lot number (grave number)
QName of Sexton or Person in Charge o Premises l hnoc JIwaif-
2 (please print)
44 Signature NIL— Title Colt 61RTOL
DOH-1555 (10/89) p. 1 of 2 VS-61