Griner, Anna NEW YORK STATE DEPARTMENT OF HEALTH tatib L12
Vital Records Section t. . Burial - Transit Permit
i Name F-rst ,4 Mi dle Last Se
at Age If Veteran of U.S. Armed Forces,
:: Date of eath g Q
l )- — l- fV— / ( War or Dates 4)
14 Place ath Hospital, Institution or
Cit , Town rVillage f tp/sdevpiA Street Address (?kLS&s XeiLii5 (eta pars/1113 //!in4.--
0 Ma DeathaUitural Cause 0 Accident 0 Homicide Ei Suicide ElUndetermined El Pending
3;ti Circumstances Investigation
tu U Medical Ce r Name Tin, a 6
lin Ad ss
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Deathty Certificate Filed /62 /`� District Number�� Register umber
0111 City, Town or Village /a v. . d ,� f[j
❑Burial Date C etery or Crematory
!04/a` �o t1/c-- A)Ayiet3 eY a�A "�
❑Entombment Address
; cremation
( 0ee, 5,4 147/' '
Date Place Rem6ved
t ❑Removal and/or Held
and/or Address
I= Hold
0 Date Point of
i10 Transportation Shipment
C by Common Destination
Carrier
s' Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
<; Permit Issued to // �/ Registration
Name of Funeral Homec ,4Ai-ci L.— " ` // ft-i-iveVA( %Y 7
Address 3 J Z d�� I dz e 7,
Name of Funeral Firm Making Disposition or to Whom
14, Remains are Shipped, If Other than Above
2 Address
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' Permission is hereby granted to dispose of the human remains des ' ed abov as in -cated.
Date Issued iglxy 40/1--Registry ital Statistics fig -)r+i '\
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/ (signs
District Number /�o� PlaceC6► eh03 A A)`/' ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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4 Date of Disposition 1Z-2i2'11 Place of Disposition '?,, `�
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2 (address)
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CC (section) got number) (grave number)
p Name of Sexton or Per on in Char e of Premises , ,1 k* Lid
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Z (pl ase print)
Signature Title C_ rot
(over)
DOH-1555 (02/2004)