Schniebs, Ursula NEW YORK STATE DEPARTMENT OF HEALTH t 4 (I C t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
RSULA SGl-011c1iS re:444 a:
Date of Death Age If Veteran of U.S. Armed Forces,
.`i5!Oj, A. ,q(;s. 77 War or Dates /WA
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Place of Death Hospital, Institution or Old Z eseri 7a.,dt1
j City, Town or Village Z, FWro,,/#,) Street Address /�?1LI/ g NYC` /iot 6n r
Manner of Death 0 Natural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
IILI Circumstances Investigation
Ili Medical Certifier Name Title
CI G//4)Z a':.)-SR4) ) Alp
Address
V /°/ '1Z.,C. 7 j} i Z Ai g UTOWaJ, AJY /A 93.2
•Death Certificate Fi ed District'Number lJ5s_o____ Register Number
City, T un or Village ems,Z,,A4 711TO.J u .vy
❑Burial Date Cemetery or Crematory
['Entombment Address 144COAA7
54Cremation . ,+ Q.clglxi,t I A J 100�,e„i d 1t 4/
Date Place Removed
Z�= ❑Removal and/or Held
and/oldor Address
fa H
O Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home/Y/4AZ/?n„ 1/JJC ()/q ?.5
Address `
li U 2/0 '5i12Atl1R c lia, I_Ai PtA kip J-
heo, Z W<
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
• Address
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Permission is hereby granted to dispose of the human re ins scribed above as indicated.
>'> Date Issued !. _ O/.R Registrar of Vital Statistics /
(signature)
District Number/Sr) Place e7
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition yl?i.hht Place of Disposition ,,Uka (_ oru,.r
2 (address)
CO111
CC (section) A . (lot n ber) (grave number)
GName of Sexton or erson in Char of Premises �(/ �►-
z f (please print)
Signature Title CRk Mll-tOi'i'
(over)
DOH-1555 (02/2004)
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