Germana, Mary F fY
NEW YORK STATE DEPARTMENT t W HEALTH Burial - Transit Permit
Vital R Sept '
A
Neon Fast Piddle Last Sex
L . C6�2I, Y /'c- j iz &
D of477 if Veteran of U.S.Armed Fo
y
4, War or Odes ,tii/V
Hasp --`
�t�1 �r ���
1=hViegile 3 0,4,WSCUP 1i Pi-cW /rz (-el uiJ
Manner aDeao Mt4ieduralcane OAccident 0 Horaidde 0 Suicide a Undeasmined Q - - ,.. ,
. ' Medical Cutler Name - ' h
..
17 437 . 1.0?A1 Si-. (iJ gYW(_E;^/J s au1 , pi , /a�' .s--
T= Red pistrjct Number ' Number
Tfl q1r Viiage \D iku_s#y I2 C' c5--- . � `5-
Date r`
CIBuriod 2-12 /,o & f r,& Lit c.--L .
$'' cemMion Q v r /6 vd -Js 60 A�. . J 2-Pri
nee '
Hots
a Date Pointot
0Trarspodathon _ Shims,*
by Coalman
--
Date Cemetery Address
Pend issuer)
Nano of alp Home �. k ,err,�l HvrK.� �- 0119 L-f
Nunther
Address
li LaCa4 st • Giteer uri-t N_ii. 12 -t
Name of Funeral rum Making Disposaion or to Whom -....
Retrains are slipped.If Ober than Above - -
• Address
Permission is hetneby granted to dispose olive human remainktiescribed as indicated.
4S
a:M1
Ds*issued ?/ 0 11.2 ck)b Registrar of Nhei Stars** _d Q ogneduro
mum Number, 0 s 5 Pince Siw, ••f-(2- J •)h.7 b(in
I h►au*lie mains of the decederrt itieniimd above were disposed of in reco rdance wigs ibis permI on
Date of Dispos on 2 - 23.0(i Place of lion /2i ,d L,yo b1 G 0:4,-,A+4o R.• i,,fL _
(stickers)
31. Y (kit'tundras) (grave-""_'__)
- Name of Simon or Pewit'in Maw at Premises 6'4 n- a-R,4AA--4
(please print)
rc Sr YussS i 6,1 ,./ , ',ce(/( T c4i=". 1 m1.0/.., _
""1� (over)