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Wall, Emma Raine
NEW YORK STATE DEPARTMENT OF HEALTH Burial - TransitPermitVital Records Section Name First Middle Last Sex CP.-%ma RaI.,e W all _ _ Fcm4 /e Date of Death Age ( If Veteran of U.S. Armed Forces 7/1--i ill 301.j 1„,4_.._ , War or Dates __ }- Place of Death Hospital, Institution or Z City, Town or Village ' Street Address Cj tn-:- //t . Hoy ! 0 Manner of Death Natural Cause Accident fl Homicide El Suicide ri Undetermined' n Pending W _ Circumstances Investigation ill Medical Certifier Name -- Title Ne Address r , -[ P,( ( 'a/ Death Certificate Filed District Number I Register Number 6City,T-ew+rorI iU r;l. ci„s /s j I ❑Burial 1 Date I Cemetery or Crematory ©Entombment - `'��! � _..__._ Address RI Cremation ' fOe pc/L. 54- ve ilj 1lb N.4 f2 f . Date Place Removed 2 7 Removal ; and/or Held 2 and/or I Address _ _ t Hold i.._ __ f T Hate _ ___i_ l `" Point of NE Transportation Shipment 5 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date 1 Cemetery Address Permit Issued to �^i j Registration ation Number Name of Funeral Home J /- F z( !6�n ._ / , ,_ma c _ _ _ Address 1.0_..._. _a�.st- �/�Aso� _ mil(� ky 0,4' Name of Funeral Firm MakingDisposition or to Whom _._ m I- Remains are Shipped, If Other than Above 2 Address_____ 1:1. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 7/2 )lOZ1 Registrar of Vital Statistics �Q1�1 V e (signature) District District Number 660 I Place C,b-15 ) A t tS, /v\) I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition fir..,,-_ Place of Disposition _ pi nc.� y;c, j GMtn4irfy (address! w En _._ (Y (section) (lot number) (grave number) pName of Sexton or Person in harge of Premises _ jCnleY__ S ,Z (please pant) 11J Signature ._ 24 -__ Title Gr(dv►nqtf (over) DOH-1555 (02/2004) Public Health Law Sec. 4145(2b) .i . . 4 9 . 1 Receipt Human remains of delivered on , 20 ,Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# , -.