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Wicks, Margaret
L113 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex 'Th R2C R ET- FT►v R LLD I CI; -VF,m is LE Date of Death Age If Veteran of U.S. Armed Forces, . 61i>-\-C--mb i=,(z,_ a a G(o 1 3 War or Dates 1,1 i A Place of Death 1 Hospital, Institution ort City,hewn L44laga C f0s •VALES Street Address Cy 1E1v- LLS Vi-OS P 1 TftI_. p Manner of Death I Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ri❑Pending l Circumstances Investigation at Medical Certifier Name Title O n ©-Ff In A � `I Y\f�(c� `'YY�� Address Li CAE.10 .•f C-t.Ea�.s >✓Ls -V'1 ` v (`KZ 1 D..D..., -0 I Death Certificate Filed + District Number Register lumber City, T-ew of V-Rage-- l�(.F-N)s FALLS S 6 O ) '/6 7 0 Burial Date E Crematory ❑Entombment 9 / a�) ` oc,6 \i1 Eu) �EMRTORI.CA ilk- . Address ►:' remation Lk,AKECz koAD, G►,U,EEQSL3Uf }`-"� EL3ADR.K \a c'i Date Pla a Removed Z ❑Removal and/or Held - and/or Address — Hold U) O Date Point of 5 0 Transportation Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home �- �� Yo ce_A t E) }YJ C, 01't I Gi Address C\o YY1oKY\--PAtAI& T kE, C .ofzc - `� ` czK \ age H. Name of Funeral Firm Making Disposition'or to Whom ((JJ Remains are Shipped, If Other than Above • Address CC II fl Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ' s' (; ., Registrar of Vital Statistics R4 su+14- C:.,6 /LAJ ) (signature) District Number560 + Place 6 trov,s F t \s, N y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: lI Date of Disposition ti /a c /6 L Place of Disposition t,AA v ..,, C r,r,- f u f, v h. 2 (address) tii Ca Ili (section) (lot number) (grave number) ci Name of Sexton or Person in Charge of Premises C i,r,s S.,,n r tt. (please print) ili Signature 6 1,w L--,-e&--- Title Cram'*-1 u r (over) DOH-1555 (02/2004)