Ross, Carla J NEW YORK STATE DEPARTMENT OF HEALTH 4 12
s.
Vital Records Section Burial - Transit Permit
Name First Middle . Last
�l Sex F
u rICI-- J I
Date of Death Age If Veteran of U.S. Armed Forces,
11 )2-01Z- 5� War or Dates
#- Place of Death �I�5 ��� Hospital, Institution or 103
� �r� 5 r_
W City, Town or Village Street Address
0 Manner of Death Di/Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
III Circumstances Investigation
tu Medical Certifier Name se Title
0 sea
5a>>r1 aGkoc
Address
Ioo P0-r\I\Sb C lens Sa11S 0, (ZC>l
Death Certificate Filed G lei5 R 16 District Number 01
Register Number 6/ i3
City, Town or Village "1
['Burial Date lit- I2G2Z Cemetery or Crematory (fir �ju�
❑Entombment ne V�eu. - t�
Address IC + `
L remation UU•eecr�s ry kJ
Date P ace Removed
Z ❑Removal and/or Held
and/or Address
-a Hold
f
0 Date Point of
%0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to ll__ -- /I'' 1 Registration Numf�gr1 I
Name of Funeral Home 1 1-11CI -MC tC 0-at Yk rn ``'1
Address q Pine 5. CkT kUJf Pt) 1 Z?)-1
Name of Funeral Firm Making Disposition or to Whom
fia Remains are Shipped, If Other than Above
;'i Address
Ir
I !
Permission is hereby granted to dispose of the human remain described above as indicated.
Date Issued I ILI kc 9 Registrar of Vital Statistics CCU
(signat
District Number SEA Place C e! I is
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I / S I ZZ Place of Disposition ,n-cVn-.� ..Jt-d s. "-
(address)
Ui
CC (section) (lot umber) (grave number)
CName of Sexton or Person in Char a of Prem. s aris1,-- $t.v4t
z (please pnn
Signature
s- Title
(over)
DOH-1555 (02/2004)
c
Public Health Law Sec. 4145(2b)
Receipt
Human remains of j delivered on , 20
Pine View Cemetery Representing the funeral home named on burial,permit
Official Funeral Directors Reg.or License#