Dapiran, Mary C4
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section i Burial - Transit Permit
Name First Middle Last Sex
"m ea �YR ANLOCA fie lR Rq VEm RLE:
i Date of Death apik Age If Veteran of U.S. Armed Forces,
Wk_ S�- ra 1 /o 9 3 War or Dates ‘y J A
1- Place of Death Hospital, Institution of
. City, Town-er Village a tiEl y, - A L Street Address
a Manner of Death❑Natural Cause 2 Accident Homicide Suicide Undetermined Pending
..--Circumstances Investigation
La Medical Certifier Name Title
Address
t 7malgaR (Rw6 C uFE,KsEctt :r 1 ara i
Death Certificate Filed District Number I Register Number
City,Towne- ViU f�age (s LE cL L,S S OO l 1 k-i'E%S
} OBurial Date Crematory
90 C-, a.. ) 4t3_0(1, Ger7c)ie.c.c.3❑Entombment Address
c_REpm\mizla rv---
'_(�
r.i remation cj-\ ( t.(AkF,l; -4. �t.k&-f NSRc(f ) I b T
Date Place Remove
: ❑Removal and/or Held
and/or Address
f Hold
VI
Q Date Point of
19)"0 Transportation Shipment
i by Common Destination
Carrier
:,,:.
Disinterment Date Cemetery Address
aReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home - �n j .-f,t F,__ft1 C E,) 1 N C, f 1.1 l G
: Address
Q
;_:, Name of Funeral Firm Making Disposition ovto Whom
Remains are Shipped, If Other than Above
Address
ill
id Permission is hereby granted to dispose of the human remains desc b d a ove in d.
L!V
Date Issued CJ 6 Registrar of Vital Statistics
(signature)
ligi District Number t<601 Place .,t_E us VALL,si(f) E(.4D (At R.R.
g', I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill! Date of Disposition V /13 /bL Place of Disposition Pint ti,tw Cremi L",.A. •
2 (address)
LEI
to
CC (section) J (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises C h en ne st
2 (please print)
lilt Signature6 . 1^^' �' Title Cr re-n.g-}o r
(over)
DOH-1555 (02/2004)