Sherman, Pauline NEW YORK STATE DEPARTMENT OF HEALTH ` . ...di 4 in
Vital Records Section Burial - Transt Permit
Name Fife. . - Middle st S
./
Date of Deat w v` 1 Age If Veteran of U.S. Ar,gorces,
g S War or Dates
`:: ,.--th Hospital, Institution or
�;.; Place • p�
Z City, I own .r Village �� Street Address 3 i.y- /(4, � 4't .
ElManner o Death CZ Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undete fined ❑Pending
Iiij Circumstances Investigation
il M• edical Certifier me Title,
if 4 le if
Addr�s . . ljec.e....r.....7)
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i .., j XI,
Y
l D• eath Agai .cate Filed District Number Regist Number
> . -i City, , or Village ' / .Ce -I./ . `-f / _.
Date Cem or Cre 9t6ry �L-6„
❑Burial /i / 2-0 / 2— ..C.e'-,w� '�r`-�
Address
iiii El Cremation '1t1
gDate Place Removed /!
0❑Removal and/or Held
i.: and/or Address
Hold
Q Date Point of
ti❑Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
iiiii Permit Issued to �/ Registration Number
<; N• ame of Funeral Home '� „G _.cam ��=- ' 0 / 2
*iiiiii" Address Y Cr /'/ 2 lc
iiit Name of Funeral Firth Making Disposition or to Whom
' Remains are Shipped, If Other than Above
." Address
aC
a:
Permission is hereby granted to dispose of the human remai described above as icamd.
Date Issued --, /--�/ -. Registrar of Vital Statistics L //,,�� // el' J�
(Siat ,y
District Number
Place " )c/=-L,2 , 7 Z / 2 S 2. 7
I certify that the remains of the decedent identified above were disposed of((i''n ac rda/n'ce`with this permit on:
6 Date of Disposition .cl d Place of Disposition ? .VuJ `cv►cjar,_._
2 (address)
LU
CC (section) / lot number) (grave number)
GName of Sexton or Person in Ch ge of Premises / ri�`'9er �w�l
F i
(please print) 1
94 Signature ,,� � Title afelltA iUYt,
(over)
DOH-1555 (9/98)