Smith, Edith E. •
1/7 NEW YORK STATE DEPARTMENT OF HEALTH 't 4/
Vital Records Section Burial - Transit Permit
Name irst Middle Last S x
irime
Date of D ath Age, If Veteran of U.S. �ryn ed Forces,
'a aWar or Dates NCO
Place eat�� Hospital, Institution or p , � ,)Q
X. City, ow r Village Street Address 5L( WC,.,VT�'11 I1ILI Rd
Manner of Death u Natural C se ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
° KU 65,11 K i kli b
bons
A
Death Certificate Filed-) District Number Re9(iser Number
City, Town or Village Lo n q (at _ ,?D,S.,fj
❑Burial Date J meter/or C`ema ry
l t uc) d
['Entombment t i YAP V �a ./
... Addre�s to
,Igi
Cremation Le5bt)Y(, N,
Date ���J)u .-,n Pla y
Removed
Z ri I'—'Removal and/or Held
P. and/or Address
Hold
CA
O Date Point of
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to n p Registration Number
Name of Funeral Home V l t Fh e, 0 f 1 99
Addressa 7 1W6 R-' , - C) , nd ci a L a, pg.4-2-
::,::::::.: Name of Funeral Firm Ma King Disposition or to Whom
1, Remains are Shipped, If Other than Above
2 Address
cr
LU
4, Permission is hereby granted to dispose of the human remains described above as.ndicated.
Date Issued (9/5/9-1 Registrar of Vital Statistics A -"` .)4,,e.,
(sig ature)
District Number a00.--(o Place (.t)y ZOO ( k
I certify that the remains of the decedent identified above were disposed of in accordance Z
th this permit on:
I _of Disposition_ 2f fl Z( Place of Disposition -—.�(.. L,
2 (address)
it
to
(section) (lot number) (grave number)
Name of Sexton or Person in Ch ge of Premises 6�//t r" 11 l.- 114r
(please print)
ill Signature s�� Title /'Y "t( .
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) U '
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#