fetal death 07/21/2021 09: 50 5188632985 TOWNOFEDINBURG PAGE 02/02
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NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
fat4 Name First
��: �E Middle Last Sex
J1
11> Date o Death Age If Veteran of U.S. Armed For es,
� ~/ I io2. laca War or Dates f
• Place of Death Hospital, Institution or
City owri r Village DI {i bC _ Street Address ',fa() , r�S Rd.
Manner of Death❑Natural Cause ❑Accids it 0 Homicide 0 Suicide p Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Ti
CCLSI d o .l--cl
:k r r].
:kzm<hi
Address
,
It
lig Death Certificate Filed District Number 1 ' � ' Register Num
r_
M City, _l f r Village I r)
' :❑Burial Date • metery or Crematory
1k_l / p P l h V v t C. re � z
s}❑Entombment A ss i^ '
t, *Cremation (A r ils r 9(�l-4--j }e-1 (-J
`'removal
Place Remove
and/or Held
nd/or Address
oldDate � point of
ransportation Shipment
by Common Destination
Carrier •
Z Disinterment Date Cemetery Address •
❑Reintermen# Date Cemetery Address
5
€fi Permit Issued to •/y _ a�� Registration Number
i,k3> eaI u_.1,, l - rn c. O n a �
'; Name.of Funeral Home -
Y Address
' t o� Mai ►'� -f s 4 ids Q is 11, L.
Name of Funeral Firm Making Disposition or to Whom
2L. Remains are Shipped, If Other than Above
Address
•
Permission is hereby ranted to dispose of the human emains described abva as indicated.
nt
Date Issued o2/ a ( Registrar of Vital Statistics A LU ^�
(signntur
it
District Number 455s-' Place Cu--t-Q
:ter
f;a:
fI certify that the remains of the decedent identified above were is ed of in accordance with this permit on:
Date of Disposition_ -7.l 1 3 i li Place of Disposition • il.., 4r 0`_
Is
(address)
{section} `umber} (grave number)
Name of Sexton or Person in Charg f Premises /'+-----74)t 1. .�/h'
/ (pleaselbrint)
Signature Title G tlAw i'
(over)
DOH-1555 (02/2004)
9
Public Health Law Sec. 4145(2b)
Receipt
Human remains of , delivered on , 20
-Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#