Green, Claire NEW YORK STATE DEPARTMENT OF HEALTH • If 5 tiff
Vital Records Section Burial - Transit Permit
Name First Middle L st Sr.
Date of Death Age If Veteran of U.S. Armed Forces,
e %kelc r' ‘Q ,2013 °t l War or Dates
15i.4 Pla a of Death Hospital, Institution or
City, Town or Village For+ ..04..,oaretStreet Address 31 CI `6 o
ilk Manner of Death RI Natural Cause El Accident El Homicide ❑Suicide ❑Undetermi ed ❑Pending
W. Circumstances Investigation
titMedical Certifier N me Title
a 01 A 1k) 62.-o. ,m . 0 ,
Address
Death Certificate Filed District Number Register Number
City, Town or Village 1 cri.4- F.cl ca c..F,' ,�� ` — 3 0
>> ❑Burial Date p� Cemetery or Crematory
mi['Entombment Address lILl" ,5 Ply. J l-C,tso ecteNci-
®Cremation frj\ QV 0,1/41Ck.,r P.C\. Qu L 0�..�
Date Placed 0
Removal and/or Held
Pz ❑and/orld H Address
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0 Date Point of
a"0 Transportation Shipment
G by Common Destination
mi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
N. Name of Funeral Home5\r6l.QJ1 t: ``►vQC1 ?d. r- 015O Cie
i> Address
k t. latcm4
Name of Funeral irm Making isposition or to Whom'
Remains are Shipped, If Other than Above
2 Address
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Permission is h eby ranted to dispose of the human re ains describe ove indicated.
Ni Date Issuedo.„/„g
Registrar of Vital Statistic
-------- (signature)
District Numbe255--- Place iiice,/ C- 2/- ...C.'sq.Ze_ee......//a/:
I certify that the remains of the decedent identified ove were/disposed of in accordance with this permit on:
k
Ui Date of Disposition 11110 Place of Disposition •„Aiw Cnec.tfn.;r
(address)
W
CO
CC (section) (lot number) (grave number)
ei Name of Sexton or Person in Charge of Pr mises Iii,s{ b. ..,4t-
2 ( lease print)
Signature Title lgee AUTO Q..
(over)
DOH-1555 (02/2004)