Chesney, Trudy NEW YORK STATE DEPARTMENT OF HEALTH • t
Vital Records Section Burial - Tr nsit Permit
Name First skMiddle �^ Last Sex
Date of Death A e If Veteran of U.S.Armed Fares,
f --/3 War or Dates
1- Place o •-ath Hospital, Institution or
Z City ow, or Village ,i- Street Address y fil 2 ----
0 Manner of Death ❑Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ILt __ _ _ _ Circumstances Investigation
uj Medical Certifier Name _._ Title
12 j1
.4-.4
Address -- bt/" - Ifni/ - - - -
Death Certificate Filed Di ict Number R gister Number
Jr-Cit , own Village ,_I ,p,,7<
_
['Burial Date > Ceragjery or Cren)atory
❑Entombment -c i , Imo"r°I,/ L�-✓P A't 7
Address
remation
Date Place Remove
Za Removal and/or Held
and/or Address
N Hold
0 Date Point of
a❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address -_-- - -
Reinterment Date Cemetery Address
Permit Issued to -- I Registration Number
Name of Funeral Home (' I ic.�i - )- ( kt i" F L.,lE 4 ( ( • ` 1 )
Address
i i Lct-v Vc-4 -H c- i t cc 1 , C ktt'c' ( 9-)( r y , w'c ti,' yc>r \< i ( ;< 1
Name of Funeral Firm Making Disposition or to Whom
I-. Remains are Shipped, If Other than Above
2 Address --
Cr
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued) tOt ) Registrar of Vital Statist:1s -i..----.` Q ��5� „
_ (signature)
District Numberc --) Place b 9 a--( CD
I certify that the remains of the decedent identified above were disposed of in accordan ewith this permit on:
Z '1
faDate of Disposition 2-22_t3 Place of Disposition - uto �' a0,u v'. _
2 (address)
0
CC (section) A
t number) S (grave number)
0 Name of Sexton or Pers n in Charge of Premises I i r6_
Z (please nnt)
la Signature L Title _-_ CliiiiiniMa
(over)
DOH-1555 (02/2004)