Amell, Deborah S51NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ye bac-� h Je_an (-�me ! 1 F
Date of Death Age q If Veteran of U.S. Armed Forces,
i
I 0 103 ) 1 ?� l War or Dates
Place of Death Hospital, Institution or
City, Town or Village Mpc2CfU Street Address
rrl Manner of Death❑Natural Cause ❑Accident ❑Homicide ['Suicide ❑Undetermined )p Pending
iti Circumstances Investigation
la Medical Certifier Name /� ( Title
CI1 ' �'Cha-e.- t S i \ r 1 c o\ . /A 0
Address
Death Certificate Filed District Number Regis r,Number
City, Town or Village oreftU //SG�. D
❑Burial Date Cemetery or Crematory
I b �u� 3 P;ne_ ..);es Cie rn c+lof j
iii['Entombment Address
Cremation
Date Place Removed
Z El Removal and/or Held
2 and/or
F- Address
Ca
Hold
0 Date Point of
Transportation Shipment
is by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M(5 C. rri es— �1 n er (2 1 1 \e CA 0—35
Address IOC_ 3rorka W a ! V r+— EGILA\CA 1 PI 1 2 F 2 (�
Name of Funeral Firm Making Dispositinh or to Whom
Remains are Shipped, If Other than Above
Address
ir
tI
P` Permission is hereby granted to dispose of the human rem 'ns described ab a as indicated.
Date Issued /p-J-/.J Registrar of Vital Statistics qP,04,6__.;
(signature)
District Number 436 a Place !�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
iti Date of Disposition JO/1 13 Place of Disposition .RN,u 4.1 C t0N—
(address)
UI
w
CC (section) (lot number) (grave number)
aName of Sexton or Person i harge of Pr mises pi„{ "^
Z (pt.;print)
Signature Title Ce )'T2
(over)
DOH-1555 (02/2004)
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