Lescault, Michelle NEW YORK STATE DEPARTMENT OF HEALTH S3-7
Vital Records Section Burial - Transit Permit
Name First M'ddle Last Sex
ifi' di e /l� 1€ Le s c4 L' //
Date of Death Age If Veteran of U.S. Armed Forces,
0, — 0 /— aO/r �.5 .3 War or Dates
• Place of Death /(o q 8 g-te 9 Hospital, Institution or
Ei Citysow' r Village 7ild Feet v Street Address / ' q y -
a Manner of Death 'Natural Cause 0 Accident E Homicide 0 Suicide 0 Undetermined ri Pending
W. Circumstances Investigation
lit Medical Certifier Name Title
r" J, kV\ /4oritol A re-
Address `�
ft Death Certificate Filed re District ber s fV Re /���tmbe
I gister r
i City, Town or Village £- S j?— I J�- Number
❑Burial Date 7/ / d y, Ce�etery or Crematory
Entombment I / l rie/e(A) Crer)'la./DJ'y ('�eeli-s 449/ Ft)Y
Address
iiipl remation
Date Place Removed
Removal and/or Held
and/or Address
I:: Hold
O Date Point of
ii;❑Transportation Shipment
E. by Common Destination
Nii Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home D.�2 Sy,�,re / ./1 fi2i Am e 1 I`, Q c2 �-d'-F
Address y� A) v i
Ji a-41 /9'e . C)/7.4/1 , /✓ i/ • L 'ra
iiE Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
#r
1,11
` Permission is hereby granted to dispose of the human remain r 7ibed ov s indicated.
i Date Issued /jQ'Y Registrar of Vital Statist(��/Qcs azti l
::::::
(signet
„„„„„,
District Number /� ' Place ' 7-)QlleCtu rUt-/ "
>.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tLI Date of Disposition '�1 TO Place of Disposition �(*�u,./
(addres)
tli
(section) f
lot number).- (grave number)
4
Name of Sexton or Person in Charge of Premises G �J W.
(ease print)
Signature Title Ctw
(over)
DOH-1555 (02/2004)