Grady, Barbara NEW YORK STATE DEPARTMENT OF HEALTH tt tig)
Vital Records Section `` 1 Burial - Transit Permit
Name Filt Middle L t Sex
br4�4. 1 Afte _ X t4 1—
Date of Dea h Age If Veteran of U.S. Arm orces,
7 -. .of 3War or Dates
Place of D ath scFp Ni,7 'TAD Hospital, Institution or �`
City, Town or Villag i Street Address E i r;SJ Try ,-)3-_
Manner of Death / Natural Cause Accident 0 Homicide D Suicide Undeter ed Pending
Ui Circums nces Investigation
141 Medical Certifi Name Title
h
c0�-,u 9, m J
Addres
f d ( ,v S` ' N� 4,.., !,11- X .Death Certificate File istrict mber Register NuD�ber
City, Town or Village �: - 13 2
Ni❑Burial Date /1 Cemetery or ematory �
❑Entombment 3 7) 1 ( X 0/3 i`/� v:c..� e. TIC/
Address
EiCremation a�C.S �.J r,-,\ Ne ,...� I yr vC
Date /Place Removed
Z 1-1❑Removal U and/or Held
3 and/or Address
i= Hold
CO
O Date Point of
lb0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to - _ Registration Number
Name of Funeral Hom e n S,u rC k-c I`» L }-fy,.•/ . _ Da`t`-1
Address 7 / �-
6\ r,r o-r, 4v-,/ l _or; : N. ; )a 12-2 Name of Funeral Firm Making Disposition or to Whom
1.4 Remains are Shipped, If Other than Above
• Address
1r
la
Permission is hereby granted to dispose of the human re. ns d scribed above a indicated.
Date Issued F/7 Registrar of Vital Statistics
,. 1 ? (si nature)
District Number Place _,.
I certify that the remains of the decedent identified above were disposed of in((accordance with this permit on:
ui Place of Disposition mot"laphv CiwAgr+...-
• Date of Disposition 8�Zc��j3 p
2 (address)
I LI
til
CC (section) (lot number) S (grave number)
f• Name of Sexton or Person in harge of Pr miser d.,A P'"S-1
2 (pleas print)
Signature �s----- Title Ca-0'410e.-
(over)
DOH-1555 (02/2004)