Rhodes, Pauline NEW YORK STATE DEPARTMENT OF HEALTH 3
Vital Records Section Burial - Transit Permit e t
•
Name first Middle Last Sex
a4 n e. Loui% -..rod e S 1F
Date of D ath Age If Veteran of U.S. Armed Forces,
�� 1 1 3 War or Dates N
f. Place of�eath Hospital, Institution or
p
City;9w n r Village P\C '1\ Street Address '\i 1 A co 'j 1
0 Manner of Death A Natural Cause 0 Accident El Homicide 0 Suicide riUndetermined �Pending
Circumstances Investigation
tu Medical Certifier Name �l Title
Barney P,tAb ec; +n
Address
5 Li-, lbe(4- .i a cY.\br ( Y 1261 to
Death Certificate Filed District Number67r Register Number
• City, Town or Village
❑Burial Date j Cemetery or Crematory
DEntombment 07 �� I I �% l� v h c Q \-Oc`J
Address A1 j Cremation a Ytu CY3, vo12'( b=�r�/ Iv12
Sou( .
Date Place Removed
❑and/or
Z Removal and/or Held
2
� Address
U
Hold
{ Date Point of
t�3
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to ` Registration Number
Name of Funeral Home 1 1` t)r(\Q 14W1 .Q TKO 0077
Address , A,r (t /V V 12 S4 1 he—,_ S�
Name of Funeral F rm MaTng Disposition or to Whom
Remains are Shipp-d, If Other than Above
Address
LU
CL
Permission is her- +y granted to dispose of the huma remains described above as indicated
Date Issued 7 J� Registrar of Vital Statistic (signature)
District Number 1111-)a.. Place q 1 tAl 1-,r
I{, I a $01
I certify that the re ains of the decedent identified above were disposed of in accordance with this permit on:
ILI U
Date of Disposition 1-5-aPlace of Disposition ,�, ,cv Crl trrlA.,
2 (address)
LU
r•
C (section) l/ (lot number) (grave number)
Ct
Name of Sexton or Pers n in Charg of Premises ih r,at r s4�,,i}
2 (please print)
Signature
Title CA,'Y'Wrt 0(L
(over)
DOH-1555 (02/2004)