Cline, Grace NEW YORK STATE DEPARTMENT OF HEALTH 1 It II
Vital Records Section Burial - Transit Permit
Name First 6 Middle Last S
Date of De�tit Age If Veteran of U.S. Armed Forces, 1
) 6/ a®+3 <iv War or Dates
}.:, Place of Death _ Hospital, Institution or
Z City, Town -Villa Street Address 9 o .--"
Manner of Death C Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
be D r 5,n'..r�n. ,/tit..D
A dresPGliq -.14,-..
e. 6r; !'i A 1) Ate,.
• Death Certificate Filed /', District Number Register Number
City, Town or Village C_-3 r — 6 `" •
Date Cemetery or Cremat 1
11 ..J Burial ( l 7 �` vl _ i _ �� �"'a-
Address,,‘ v
V Cremation u.e.����fa�r M P� iar/C_
Date Place Removed
ZO — Removal and/or Held •
N and/or Address
Hold
O Date Point of
Transportation Shipment
E by Common Destination
Carrier
—Disinterment Date Cemetery Address
—Reinterment Date Cemetery Address
Permit Issued to _ Registrati Number
Name of Funeral Home ns.Ms Acr-( p...-.) ._Lc 00 r7`K
Address CAS 4 x Air r lv,f. ivyigoki_ .
Name of Funeral Firm Making Disposition or tor Whom
t Remains are Shipped, If Other than Above
FAddress
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Permission is hereby granted to dispose of the human r ains scribed ov s ' icated.
Date Issued ( l 7 /.?v1.3 Registrar of Vital Statistics
a re)
District Number ,--r-S j Place rft.r-
/ I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Dispositionfri
Place of Disposition t,„1 {,..., .,.r Ida �"
2 (address)
uJ
CC (sectio ram` f�(1,4 rnumbey) (grave number)
0 Name of Sexton Person in C --.% - .f Premises /��l d
Z / (please print) f
W Signature <�iv!- Title ()K T/Y�/4i�-//
V.
DOH-1555 (10/89) p. 1 of 2 VS-61