Austin, Eunice NEW YORK STATE DEPARTMENT OF HEALTH (1 5
Vital Records Section Burial - Transit ermit
Name First Middle Last , Sex
runice Aus-F1A P
Date of [Id�eath Age If Veteran of U.S. Armed Forces
S'1 L- 13 15 War or Dates N//
Place of Death Hospital, Institution or
City, Town or Village 5e4 ay IeI J►)!€ Street Address
Manner of Death®Natural Cause LiAccident El Homicide El Suicide Undetermined Pending
Circumstances Investigation
us Medical Certifier Ne� Y Title
�ddress
r4-1e She 1 %ccy...-oc„c.. SP. /l/f I ze66(,
gi Death Certificate Filed i District Number Register Number
ipV City, Town or Vlage, &htly f. r U t 1 ( t7 'I5,4 5 a
;<' OBurial Date Cemetery or Crematory
DEntombment 5":16-- 13 Pi i1e'_ Li iew 6&e t't3 r
Address
i•;' ®Cremation 1 u� 67. a,,,-,s h ,v �J
Date Place Removed / /
Removal and/or HHId
rn and/or Address
: Hold
to
0 Date Point of
` Trans potation—❑ p Shipment •
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home L Oyh pc.,SS tcrckyleiiiiilp-L.1 (cu e03Cc(
Address 't
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tii
„•
' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5-/(, "aU!3 Registrar of Vital Statistics £ ACIJ
(signature)
'< District Number 44 5 a5 Place 4 e 1 . f,L� 14 .
,+�
kI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
tit Date of Disposition s 1 W I Place of Disposition .."Fekttki arrctof l�
Ui
(address)
fill
re (section) (lot number) (grave number)
0
iz Name of Sexton or P rson in Char a of Premises A,) T Ayr
2 Tease print)
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g
Snature Title (1140110fIj}/�'
(over)
•
DOH-1555 (02/2004)