Bessette, Marion 3 NEW YORK STATE DEPARTMENT OF H LTH V . * # (0
Vital Records Section Burial - Transit Permit
Name First AA Middle Last Sex ,+
/ / prated) u z. 19- Z 6re ��[s . Fij),8L!l'
Date of Death Age f,lf Veteran of U.S. Armedyg-
es,Foes
51/y )g P2 War orDat
14 Place • Death Hospital nstitution
X City, own .r Village Td,(�,J S L U Lc Street A ,lQ j t Dt9-C'k- /'h-1 (..Q
Manner of Deaths Natural Cause Accident Homicide 0 Suicide Undetermined ❑l ding
ILI "� Circumstances Investigation
W Medical Certifier Name .�— ' ` Title
a I) fl -f �1' "''1-1 ei 7?) ,
Address i? /� /'
11Z �)L1 ICU�1tr 4 ,AjD ert,wi //U
Death -a ificate Filed District Number Re - ter Number
City, ow r Village To AJ.Jf e L'2-5 i O� c,
OBurial Date c, Cemetery o Crematory
❑Entombment / �(��, I , U)
Address
'5'Cremation U
u A'k' -- Y41 a 0 erifritLrE My /
7
Date Place Removed
Z n Removal and/or Held
D and/or Address
N- Hold
N
0 Date Point of
O Transportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home \i-Ne_r V�clt,cr. \ hp c c\ (7)11 . G
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address _
it
Ui
Permission is hereby granted to dispose of the human re in describ above s indicated.
Date Issued Q- I<-a)) Registrar of Vital Statistics C'
(signature)
District Number 5‘SS Place :'• 4 ..___ *V-
: I certify that the remains of the decedent identified above were disposed of in accordan a ith this permit on:
Z
ail Date of Disposition iI11117 Place of Disposition P 7nj) ��".4.71`..
12 (address)
(I)
cc (section) (lot-number) (grave number)
GName of Sexton or Person in Charge of Premi s � S�Nt
Z (pIEse print)
Signature it
a ►qt-- Title /��,r+r►�t.-
(over)
DOH-1555 (02/2004)