Whipple, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH c ._;_._3 -c 7
Vital Records Section Burial - Transit Permit
n Name First
Ar /n Middle Last Sex
/ / L TO tr /\.( CO MN , &)vj/ Pr1✓, + a-r
[ Date of D "ath A e If Veteran of U.S. Armed Forc s,
&- I el (p to) ns or Dates JO I/9-
Place of Death (� j"` ospitajnstitution orn
Town or Village Lax.)s / i 4 treet Address 4 Lg7A-)S ES-LC-S.
anner of DeatfNatural Cause Q Accident 0 Homicide �Suicide Undetermined Pending
.l Circumstances Investigation_
. Medical Certifier Name �' Title
/
A o e.. U...hr J 6-206,.�1 S J
Address (-f
r. al-f...)s-
......
i.•..•.i.••
tu
in D th Certificate Filed District Number 1 Register ber
:'ON
Town or Village Cce ^)3 � t, $ 5 60! 3
Date J Cemetery or remato
❑Burial �/ cf 0(P ,...)�-- V/E )
"C Address//�� gei
�, //` remation lit 007(b� )1Jt.�nf S CU ) l
Date Place Removed 3
0❑Removal and/or Held
rf and/or Address
5 Hold
0 Date Point of
0 Transportation Shipment
t by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
€ <l Permit Issued to Registration Number
``� Name of Funeral Home Alto \ 1, /R1 0 F,�6 , ) iC 0 j)91/
Address // J
: If L 9 y6,r tom' CT, 0 u "s 4 U /2.�d y.
:. Name of Funeral Finn Making Disposition or to Whom
i
PC Shipped,Remains are Shi ed, If Other than Above r`'
Address
Mil Permission is hereby granted to dispose of the human remains described above as indicated.
.. Date Issued ah J 6-6) Registrar of Vital Statistics M-Ct O/tA) V.)
II (signature)
•....
E District Number 5C) ) Place 6 (svv-c t \ S� N q
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
W Date of Disposition 3/ti/61, Place of Disposition Pjievuw Clcm4 url./n.
2 (address)
iiiCfi
(section) r (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises L' e,S Se„t- ,
Z (please print)
94 Signature ,iiiiti„ Title
- (over)
DOH-1555 (9/98)