Lynch, C. Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First 1 Middle Last Zex
Date pf Depth J J A e If Veteran of U.S. Armed Forces,
iC t (1 .' . I War or Dates`A.,c
14 Place of Death Hospital, Institution or
(Cit Town or Village g.11 . it') ati Street Address z(l c u i Jec
ui
a Manner of Death FA Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined Pending
titCircumstances Investigation
W Medical Certifier Nam Title
Address2 //A,, j/)
y_foe:4
Death Certificate Filed �v ) Distric N Register Nu in.,/
,'Ci Town or Village j 4d �51oL)( g o2 7,
Burial Date�1 J etery pr CremI�ory
['Entombment04 //.3 l D (r' I .r i i J Ck a n� 1-6 t.-
Addees a
Cremation c- (Li -n,,1.I)4,;, 1,L.• )1,'�
Date ;f ! ace Removed
F. ❑Removal and/or Held
and/or Address
= Hold
to
0 Date Point of
Transportation Shipment
Q by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to J�_ Registration Number
Name of Funeral Home LeL,'-C.,j\3j,Li . i. tits- / ham, Cit9 0
Address
Name of Funeral Firm Making Disposition or to Whom (J
Remains are Shipped, If Other than Above
,'! Address
LU
Permission is hereb granted to dispose of the human remains described above a • 'cated.
Date Issued 06 /r/04 Registrar of Vital Statistics Ahtl `Ls
(signature)
al District Number 5 7/ Place G/- fail/,/Ly
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 6 13-o(Q Place of Disposition p, NE IAt R t, C E,44 .-t-d/Z i v
Ili
(address) 1
til
ir (se tion) //�� (lot n mb r) (grave number)
klCi Name of Sexton or Person in Charge of Premises � LT�'�
2 (please print)
Signature CQ- Title e l�E..m 14- `
(over)
DOH-1555 (02/2004)