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Mallory, June
NEW YORK STATE DEPARTMENT OF HEALTH Atal Records Section Burial - Transit Permit <s° Name First Middle ,Last ex �...i i_v� i C-, VY�C�.!i a►/ wtc .�-� Date of Death Age If Veteran of U.S. Armed orces, 0.-,&b - be 3 _ War or Dates �I&. 44 Place of Death p Hospital, Institutio r (� City, Teams or Village ( L.rze-,s ��c, Street Address({)-,' ct--i �S .:-"O'caD \ Manner of Death qNatural Cause 0 Accident 0 Homicide Suicide Undetermined Pending Circumstances Investigation tt Medical Certifier Name (-- Title JC)h. 5 -6��--�_.- ,t,( ivki:-__) Address , ' 16 �y� qs rl� l a i--th -•-.ificate Filed D Ditrict Number I Register Number City, - o • - Cie --f .R Sty© i to wg Date Ce etery or Crematory urial 4-D_q-b(o pu s,dl€,, (-e-wt��“Q-tr Address Cremation V� . Date I Place Removed 2❑Removal and/or Held ..• an Hold d/or Address M 0 Q Date Point of Vt?[]Transportation Shipment Q by Common Destination Carrier Disinterment Date Cemetery Address Renterment Date Cemetery Address >!i Permit Issued toRegistration Number Name of Funeral Home . ,,, .;,�,L Zt_tne_ti,--- �� O S�i :iii >< Address ----�t f.�tt Q- 'use Sbuty25,-- ,Mi Name of Funeral Firm Making Disposition or to'Whom 1 Remains are Shipped, If Other than Above Address Cr IA IX --„. gt Permission is hereby granted to dispose of the human rem ' described ov a ' die .d. ?! Date Issued 4,4 "- ''4 Registrar of Vital Statistics ;;�` -�-'� & �S re) li District Number S�5 Place 40 LEY1 0. ` :;.).4., , ,� �., FI certify that the remains of the decedent identified above vie disposed of in accordance ith is permit on: Date of Disposition Place of Disposition J 2 (address) Cfl CC (section) (lot number) (grave number) QName of Sexton or Person in Charge of Premises Z (please print) W Signature Title (over) DOH-1555 (9/98)