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Norton, Olga
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section ?> Name First Middle Last Sex ::.:. •:A. ,_ •.«,vn,ww•+v:::::nvnv:nvrrc:r::.r•'• ....•••.•....::::::.:v�,v:m:... Date of Death Age If Veteran of U.S.Armed Forces, ' War or Dates J�/ovrm b r %99'7 7 rs:.......::::..,. ....................... .r..»n. . .w2 ,x ,rcxn. 'Place of Beath Hospital,"Institution or o n o- 2 i " `Ztreet Address .�O" • `i(�ld�e. 1-0- ' -/S cZ City TOWnCr Village -Al)Q SAa?i X of i?':�•:•...... ..nvv:xxrnvxvxwr.w.v.�..-...w..wn•r...vnwxx.,•1•.vv:hv::x.•xx:.w::...:.�,x::xw.v:::nv::...,•x.w:.vvnv::::::::::::::::n ..::e.. A' Manner of Death Undet mined Pending Natural Cause Accident Homicide Suicide Circumstances Investigation v;.:........ w n,v: n,.....,nn,w.,,.,.....,,.,..:...................................:.:.:.,......,....,,,,..:.Tills,....,......,.......,.......,...,w...w.�n,» ..x..v::nxn.v.,.....:::.n..................:..., Medical Certifier Name o �81 .... ................................,........................._..... '.................. ..................................................................... �:.ess l ,80 x � Ti codel- Death f .................... Certificate Filed�our r� o �.:.......... ` District Number : Register Number City,Town or Village PU cj M S f'Q f7'o A 1 J 7&3 .� Date CerD.etery or Crematory OBurial yre 6 C'r .:/..9. �I- �i'1')c2 7��/` '© : , y ' .� . ..::.,.. n..rcx.: Cremation Ad rest z'> Dale lace Remove 2 ❑ Removal and/or Held F-< and/or Hold Address :nw ::::,..:..:............:.................:;_:..:. ,...::::::::....:.:: _ ,......:.:.....:. ...::.,. �. O ........:::..:....:::::...,..:.:.::.w::nw:n.:.:.,.:.:n,.:.,..::..:..:.:....::.. .:.::::::.:::................................... :...:.. ...:..:.:::.::,.. ... .. ...... ..... ... ......... ............. . ........... n< `: Date Point of cn Transportation by : Shipment p' Common Carrier v.,,.:::.,..,.n,:..,..... x,::n.,n. ......... ....................... ....................... .. ......... _ . Destination ................:.,,:.,..,»,:nw,w:w,,.:.::.,.:.,..w.::. w.:n,,,,,.:::.:.,.:::::::.::.:.:...........::::.:.:..:...:.:::.:::.:.:::,:::. ..................... ...............:.............:............................................................. ..... Disinterment Date Cemetery Address ..........:.:........... ".....:::.:.......... ............................................................. Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Firmi �C +- �v....n� ..©�( Address _ � j A &7�dq Name of Fune�Firm Making Disposition or to 14hom Remains are Shipped, If Other than Above vxwwwwnwww ..........................:.,.................., ........................................................:...........................................................:.:. ww. wnw. ............................................ ............................................................. _�• Address Permission is ereby granted to dispose of the human r mains ode ribed above ps Indicated. Date Issued Registrar of Vital Statistic --�-, (signature) j District Numbe Place / C�La 'I� Q ' At „ ,__=C I certify that the remains of the decedent identified above were disposed of in accordance with&s permit on: Date of Disposition �� Place of Disposition �! �f ;5 Lu (address) 1t14 (section) (lot number) (grave number) p; Name of Sexton r Person i Charge of Prem' es Z (please print) /-- i/ Q I w. Signature Title� /)'/4�1 /]56! / ' DOH-1555 (10/89) p. 1 of 2 VS-61