Ladd, Audrey oP LN j
NEW YORK STATE DEPARTMENT OF HEALTH • •
Vital Records Section Burial Transit Permit
gl Name First Middle L. Sex
Date of Death Age If Vetera of U.S. Armed Forces,
iiin
„.9-3 --a-.ui Z (.0 (., War or Dates
Place of Death cc�� Hospital, Institution or
City, Town or Village (.�to Street Address S �yY-
Manner of Death Q Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier me Title
Addretc ss
9
�> Death Certificate Filed � District Number Re ister Number
City, Town or Village 5i (Q E7
Date Ceme y or Crematory �} , ,
❑Burial R-7)- gbi L , n 42 �t` Q cc, Vim frx., 7 4,4^
4_
Address � ^ •
:':: [4Cremation � d ) 2 e3V
Date Place Rer i)Ved
0❑Removal and/or Held
k and/or Address
a, Hold .
Q Date Point of
1 Q Transportation Shipment
• by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiiiiiiii Name of Funeral Home —Th_(2-,,,o ri1.,IL n �Q \4 9-__ p U Y i/eF
<: Address
,<_< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address .
ILI
-
t
iiiiiiii Permission is hereby granted to dispose of the human rem fns described above indicated.
< Date Issued 7—.-v!. Registrar of Vital Statistics )_/,_ Vr
(signs ure) ��
In°
€``:� District Number ;(0 S'1 Place ���� •
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 4-t1-fl. Place of Disposition 6•41tJj i �,f»''brlw
w (address)
•
(section) t number) (grave number)
GName of Sexton or Person in Charge o Premises r i rl 3.�,,�}-
z (please print)
W Signature 4, Title OW )Wi'_
I
(over)
DOH-1555 (9/98)