Cooper, Abigal c . 3
NEW YORK STATE DEPARTMENT OF HEALTH # toil
Vital Records Section • Burial - Transit Pe mit
Name First Middle Last Se
../ �/ ,cd7'� C: , i ' 4/
Date of Deat Ag�' If Veteran of U.S. Armed Forces,
/AW /3//i/ War or Dates
.1! Place of Death 2 Hospital, Institution ,
1ZVTown or Village 6 f f//S Street Address 7_1' -�Jge,/. /
aner of Death atural Cause Accident Homicide ❑
Suicide Undetermined Pending
Lid Circumstances Investigation
W Medical Certifier Nape Title
,, // a ,/�s C/1//,/l-'7 .
Ades
sCP C 57 ge'l -r ii( .K/y/fiev
Death Certificate Filed District Number / Register NumberZ�
City,Town or Village14JJ
['Burial Date /� y�-�� or Crematory ,� ,—`.
['Entombment v / 6,/3 ��►�✓er C/C 212-t���Gt/�,iz"z_ �!
Address ! J/
ig£remation c/iCer X6 ( 2 ' r f1 c'ra/ Y
Date Place Removed /
Removal and/or Held
I—Iand/or Address
to H
� old
0 Date Point of
65 0 Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
s Permit Issued to Registration Number
Name of Funeral Hom ,f,/?7-- �� r� 177,,,i - e'd/ry
Address
ni l //AO j /�,,--/o c 7,t1---ef77
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
to
IL Permission is here gr nted to dispose of the human remains described above as indicated.
I Date Issued )--- ___7. Registrar of Vital Statistics Cis. -S- -4? (./s,
n �) (signature)
District Number S'6(� J Place 6 �y-S f k 1 S iv T
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z f`�
tt Date of Disposition $/(,!(3 Place of Disposition Rt./0/ -, etrnctOr€,
(address)
ILI
Lti
CC (section) of number) (grave number)
0
Name of Sexton or Person in Charge of P mises lot
r .SSn-cN
(plea print)
iii
Signature 7LL. Title �'1 71iTtl
(over)
DOH-1555 (02/2004)