Burgess, Mavis NEW YORK STATE DEPARTMENT OF HEALTT-I . 'f 1 tt 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
11: Date of Death QA e If Ve an of U.S. Armed Forces,
u G'F6 War or Dates K 0
Place of Death Hospital, Institution or
LILizStreet Address /a 3 L r reEq '1 e I d`j 1 Jr
D Manner oreath LT Natural Cause ❑Accident Homicide E Suicide Undeter ned 0 Pending
Circumstances Investigation
Medical Certifier Name Title
kk5cLnne FJIGod' M1b
Address
0 Lt i..t2.r')5b arti
a Death ertificate Filed Dis ric Num er Register Number
rf City, own r Village O'utel k u Aii &Si v�b
❑Burial Da e Covetery or crematory
❑ 0I (1 - 1 1 V , r 1 -e--� L.X'C i'n cd--L't y
Entombment Address 1
( cremation Gt,&U.AS rTh LAL N N
ba
Date Plate Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to '- Registration Number
Ftri Name of Funeral Home 5re u.) cir tiktv. rki 1 ilv AN _ I nC 00a
Address D"t C h cl.Y cVA. , like., L Lk 7 cam . N
or to Whom 1
Name of Funeral Firm Making Disposition
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ••-; de- -d a• • • as indicated.
Date Issued jQ-1 1 apt Registrar of Vital Statistics . _ ) ,� ;
_ signatu e
District Number GlI& Place l i I
certify that the remains of the decedent identified abov: were disposed of in acco - ith this permit on:
• Date of Disposition Plitt il Place of Disposition guU- `,i0-4,r:%.,
(address)
(section) , (lot number) (grave number)
Name of Sexton or Person in Charge of Premises (^`'. Sti',A
l ( lease print)
Signaturetiet
Title lI MO&
(over)
DOH-1555 (02/2004)