Rudolph, Gaye NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section
` Burial - Transit ermit
Na/'/m-er-)First ddle ast Sex t u
iak„,
Date if De t Age co,y_ If Veteran of .S. Armed F ces,
War or Dates
j Plac, :, Death Hospital, Institutio .or
Ci , Town sr Village � � Street Address ,/.1 .u'S,jl6 m e .
Man - of Death pNatural Cause Accident Homicide ❑Suicide ❑Undetermined �Pending
Circumstances Investigation
tu Me CI Certyfier j Npme Titles
Addy a�ss
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Death icate Filed , District Number Register Number
Cit Crown o Village , E ��,-..wr� ;S73TI
�g� Date Ce etery or Crematory/ /
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['Entombment A dr Q
;Cremation US / 'QC/
Date � Place Removed
❑Removal and/or Held
.e and/or Address
t Hold
f
0 Date Point of
t1 Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to / / _ RegistratiS)n ber
Name of Funeral Horn ,-,yot, 7L j a--Aq.- //4J'7i - °- 6)O 1� �
Address
s/1�/YrQ-/2 ✓.,P 0-6i/)d ,5.` // p,a-,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
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la
iL
Permission is reb granted to dispose of the human remains described above indicated.
Date Issued/ / Registrar of Vital Statistic
(signature)
District Number Place ./G'k. C 7. ti`f- ��a cZ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition I-6- IL Place of Disposition -w0tad 71 coy,'
(address)
id
lr (section) (lot number (grave number)
CI Name of Sexton or Pers in Charge of remises 4 IV,A- I t e'ri-
(please print)
141 4.-
Signature Title C2f t14itA/2,
(over)
DOH-1555 (02/2004)