Graulich, Donna 11. „ #i 31'?
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle /, Last Sex
JDOI)n(i. e ct/1 r)P.y (--)mtA(i c 6 Pilia iC.
Dat of Death Age If Veteran of U.S. Armed Forces,
-- ICI- i S i t i War or Dates No
- Place of Death Hospital, Institution or {{
Z City,n`ow,rlr Village firm icy Street Address ' n 1-1D/)\/ l rff K iRc ,
pManner of Death ��� Natural Cause 0 Accident E Homicide p Suicide �Unde rmined Pending
al Circumstances Investigation
tu Medical Certifier Name Title
0 .John St ;uck;') :-- NA
Address
(2))(i,►( 17_ 115 NA/
Death Certificate Filed Disttict umber Register Number
:: Cityti'' ownbr Village H(ki k' ) (' CC
❑Burial Date / .. metery or Cre patory
❑Entombment 9" - -r ` i I ir)( V I C L rt itarr
Address
®,Cremation —7) LLr' j iDt.L n' ry
Date _J Place emoved
Z Removal and/or Held
2❑and/or Address
0
Hold
0 Date Point of
Os❑Transportation Shipment
a by Common Destination
Carrier _
Q Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ..s. R,e9,issttration Number
Name of Funeral Home 3)1 ,Cr —L,L y ��1 -Hori j� I n (. (�t_iA 1
Address
(.* CI11,L rC 5-i , LC.�K.c Lu z t'rue_ NiV ! 2 S
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
1r
LU
11, Permission is hereby granted to dispose of the human rem5ins described above as indicated.
Date Issued t--f/;;1 C ' f g Registrar of Vital Statistics ,,," ,.c_ (.4...x.2
(signature)
District Number t7i c R Place lC tt;i) ,.( -�-1(4(1 l e t r , tV
certify that the remains of the decedent identified above were disposed of in a cordance with this permit on:
Z
lU Date of Disposition y/t3(ig Place of Disposition f'.jJ .i a.*.r--
a (address)
0
cc (section) d (lot number (grave number)
aName of Sexton or Person in Charge of Premises 40., jA,Neff
Z
1 ( lease print)
W Signature i Title ( NC-
(over)
DOH-1555 (02/2004)