Bressel, Mary NEW YORK STATE DEPARTMENT OF HEALTH _I
Vital Records Section \„ Burial - Transit Permit
iin Name First /1/44 Middle 0 Last Sex
if Date of Deeattju /� 0- Age If Veteran of U.S. Armed Force 1// j 9 / S War or Dates Ai
Place of Death 7 Hospital, Institutio or ,1
Z City, own .r Village /j Cc,,,,)b U7't-O c k� Street Address /70 S —L 4'z)1A'4 16 rJ / ;.rn J A/`/Cr
Mann- of Death 1. 'Iaturat Cause El Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
iti Medical Certifier Name � .� Title
41 ./7a /heM17 �03Vic. /
Address / 0 / , lJ I GKe L T . 1 r Cow CYt..O G 0.
Deat "ficate Filed District Number Registbr N ber
Sit Cit Town r Village I 1 c'U,J b Q c, /1:(2; 1/L/
Date � Cemetery orem /) U'
❑Burial /2-1-16 •� � f C
:_ Address G_,tAL. Cremation t� LE �iCiu .: Q l;'r,'- ---- - 1 Z y
Date Place Removed a
. is❑Removal and/or Held
l and/or Address
E" Hold
0 Date Point of •
Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to y Registration Number
im Name of Funeral Home t Ja.. ;j q.p )), Rj} 1 ),,1i- -r, iy6,-- 01/9 ii
Address / /(
l/ L G--7 J tom' - 0 u62::aS 6 a12Y1 . /2 /
Name of Funeral Fi Making Disposition or to Whom f I -
are Shipped, IfOther than Above
Remains h�pp
Address
CC
IN
it Permission is h reb granted to dispose of the human remain scribed abo a as in 'cated.
y
Date Issued Registrar of-Vital Statistics / ~ - I f -0
4'}
( - nature)
it District Number � Place (- �/ t2Q 0,0-e
I certify that the remains of the decedent identified above were dispirisld of in accordance with this permit on:
fT
WDate of Disposition 9/4(,/G L Place of Disposition PIA,v te,r (rn 41 c;-( yr 9 to,.,
2 (address)
w
ft)
CC (section) (lot number) (grave number)
DC6'Name of Sexton or Person in Charge of Premises t c SP„,nt bl-
z 9 (please print)
W Signature 4 te Title Cr e °cf c,r
- (over)
DOH-1555 (9/98)