Wenzel, Marie NEW YORK STATE DEPARTMENT OF HEAL fr
Vital Records Section Burial - Transit Permit
.
11
Nam First , Middle itzaLa lxh
Date f Death A If Veteran of L_L.S!-,firmed Forces,
j a-(o/ oc,, War or Dates ` ij
4 Place of Death Hospital, institution of
City, Tow. or Village77 ' k?Dw3 Street Address C i:ry(.i 1 f
Manner of Death�I Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
�N Circumstances Investigation
IA Medical Certifier klaTe Title
Address
Ukt,Ca.1 yU
Death Certificate Fil d District Number Register Number
€ City,( ow or Village�r ,Q/"?(31A,c7-Q (6 7
Date C etery'o/r CrematAr�y
❑Burial Q 1 I i s 1'�(9 Co Y11� V,0.4,l ) lts_Aict j
Address ��
Cremation
gDate j Plac Removed
Z ❑Removal and/or Held
and/or Address
17 . Hold
Q Date Point of
N ❑Transportation Shipment
a by Common Destination .
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to 1, ---, Registration Number
lig /�'� -� ,Q Name of Funeral Home - 1-�"ym ,, ,ek'y(A) 0/d(Dg
iiiiE Address O0 La ina,(--1\ Nat J A��_,�A K- i -,1
iim
Name of Funeral Firm Making Disposition or to Whom
,RRemains are Shipped, If Other than Above
Address
.IN
Permission is hereby granted to dispose of the human r ains described above as indi ted.
Date Issued I -a -(;)6 Registrar of Vital Statistics /?J/iii �_
nii:
----- (signature)
District Number 6q5/7 Place /C)(,0)1 L 7/nG' 'h(5-v,. .Q
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition/- 4Place of Disposition Pia � Cam/ 0Z t(24...1_
(address)
LU
N
CC (se on) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises-P. afr9 Al
-- , (please print)
U: Signature Title t). (2,f j�ef f±2 )
(over)
DOH-1555 (9/98)