Shufelt, Leona NEW YORK STATE DEPARTMENT OF HEALTH # -L
Vital Records Section 4. ; . Burial - Transit Permit
Name First Mile Last x
t�e.oNA shuPe11-- . x‘/�
Date of Death Age If Veteran of U.S. Armed Forces,
C/ — `/-- 9-e)/ " qg War or Dates At o
-1Place • Peath C� ` Hospital, Institution or
City, own ,r Village �c�h t-el o 0 Street Address 13 3�4 � 7
Manner of Death latural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
ill Circumstances Investigation
tii Medical Certifier me I / Title
ss
Addre/Mi" Avg- S e- 1-0101't A fi '. / acf 70
.
Death _ ertificate Filed ` District Number , Register Number
<> City, ow •r Village S C-I't 1"00 I S(o
❑Burial Date / Ce tery or Crematory
07/r 1- / e/2 - Netj/e.d el-emA 7c&..p
❑Entombment Addresspii �'`�
( .Cremation L)(t)e..e+v-3 Air y 1•i7r,
Date Place Removed
❑and/or
Removal and/or Held
�; Address
l
Hold
0 Date Point of
Transportation Shipment
ES by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Oiii Permit Issued to Registration Number
Name of Funeral Homerdahav L- Keg/ Fu,utvr( U -- do.5 i
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
ui.
t Permission is hereby granted to dispose of the hums-iv ains descr' ed above as indicated.
Date Issued /////2€J/ Registrar of Vital Statistics LA--",„.L,� .� ��co Q
' nature)
>> District Number ` J? Place C,Ii.. ‘,,,,,, kr la1:4___
Ny.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I /IZ/r1
lit Date of Disposition Place of Disposition ?Kt tint., (,myr( •urub,
2 (address)
ill
tn-
CC (section) (lot numb (grave number)
Name of Sexton o Person in C arge of Premises A�.)t l� ti i 1
r4 (please print)
Signature Title CQtz m im
(over)
DOH-1555 (02/2004)