Mosher, Crystal NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
CRYS AL La NUUi- ER F lYlHL>w
' Date of Death Age If Veteran of U.S. Armed Forces,
t t y 31 War or Dates
Place of Death Hospital, Institution or
City, Town or Village bREFmNF ILL.D CENTER Street Address ROUTE 9N
Manner of Death❑Natural Causer Accident Ej Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
DFaRBARO C. WULF= ME)
Address
Death Certificate Filed District Number Register Number
City, Town or Village Y - -- I -
Date Cemetery or Crematory
ElBurial :: , �_:_,
Address
qX Cremation UULENSf-AURY, NY
Date Place Removed
Z ❑Removal and/or Held
0 and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home DEN S1110RE FUNERAL HOlv1E INC. 005E5
Address
SHERI'TIAN AVENUE CORTN I H NY 1i_822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
`< permission is hereby granted to dispose of the human remains descr' d above as indicated.
[ Date Issued,-,,,,,;:; t)q ! Registrar of Vital Statis s
(sign re)
District Numbed , Place RE - -
I certify that the remains of the decedent identified above were disposed of in laccordance with this permit on:
Date of Disposition Place of Disposition �/t�� �ri &) C 17,&,417/1 /c��'1 /�1j
LU (address)
Uj
(section) loft/number) (grave number)
nName of Sexton r Person in Charge of Premises
(please print) �
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61