Nichols, Jane NEW YORK STATE DEPARTMENT OF HEALTH # 5 151
Vital Records Section Burial - Transit Permit
Name First Middle Last / Sex
TR-tiF /!2 AvN-,5 /V'CA b// //R/(___
Date of Death Age If Veteran of U.S. Armed Forces,
__
NOV. c r ZO/Z e' 7 War or Dates A,(G
j - P .ce of Death Hospital, Institution or, Town or Village PAT-7st l/n b Street Address vf/ /YPp/Cil4#Te
.nner of Death®Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
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Circumstances Investigation
W Medical Certifier Nam Title
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th Certificate File District Number Reg umber
Cit Town or Village (pg-r75hu�yi� 9
❑Burial Date
/ meterypr Crepatory
['Entombment Address
b �/Z I(A�J( V�e� e41/4?DAL(
Address Cremation (../F.,- -wsA4',2 t, /2g-OF
Date Place Removed J
Z Removal and/or Held
❑and/or
Address
tO
Hold
0 Date Point of
fki❑Transportation Shipment
L by Common Destination
Carrier
❑Disinterment Date Cemetery Address •
❑Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home M( 11/ �- ' ig4IIr2/L Gt,e,t/1/ /4,,r Cb //,3 c)
Address i/ �A 1� P're s?., Ouc /(/.v /zc 7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;2 Address
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a: Permission is here y ranted to dispose of the human remains descri d ove as in 'cated.
Date Issued Registrar of Vital Statistics �l . �
(signature)
hi District Number qe5, ` Place
'-' I certify that the remains of the decedent identified above were di posed of in accordance with this permit on:
ILI Date of Disposition >l i-11 IL Place of Disposition '(f.[V uw L tot ial-:
(address)
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Mt
(section) / - (lot number) l' (grave number)
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Name of Sexton or Person in Charge f Premises G t+� Qq��t
(please print)
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Signature L
9 Title ,M 4 i Off
(over)
DOH-1555 (02/2004)