Dark, Mary 3
4 1 7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit PermitVital Records Section
Name First /j1aY Middle IV1 Last 0.v( I Sex r
Date of Death Age If Veteran of U.S.Armed Forces,
I 0 I R 1 i -1- War or Dates
Place . •eath r� � Hospital, Institution or 2s Jidd Vi�ic) 2oad
5 City, or Village Uvt.„e2NouY ) Street Address
® Manner of Death,,Natural Cause El Ac>;ident El Homicide E Suicide ILI �Undetermined �Pending
Circumstances Investigation
LI
Lu CI Medical Certifier Name Address����I �� ' � I Title ��
�� l
101 ?c�Y 1� . G u.ns FiZW 1 N y I Z ra t
Death Certificate Filed D�'ct umber Register Number
City, Town or Village L uQ-UI\Sv. Io � j-V
Burial I Date Cemetery or Crematory
I Iul it�I 2C�I Pine_ V‘tu� Cxemc:
❑Entombment dress
Cremation C. V0.X-C.�'Y VCOC1 v gve_A is o , N .i I 01A
Date Place Removed
ZC Removal and/or Held
and/or Address
U)
Hold
Date Point of
Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
:;Q Reinterment Date I Cemetery Address
Permit Issued to Registration Number
=' Name of Funeral Home .\I-NLc ?;1Lc- \ t-10C`\t. C 11 -0
Address _
Name of Funeral Firm Making Disposition or to Whom
I : Remains are Shipped, If Other than Above
2 Address
IZ
la
CL
Permission is hereby granted to dispose of the human rem ins described a ye s indicated.
Date Issued 1 6 01 , 7 Registrar of Vital Statistics C`- _ ' ( A-k--,
(signature)
District Numbers ' Place ) d � �-( CD cI
�J I::: II certify that the remains of the decedent identified above were disposed of in accdaith this permit on:
III Date of Disposition /0[I1 I O P►ace of Disposition e<�v` � iTor a,.—
tz (address)
tifJ
ir (section) .4(lot number) . (grave number)
is Name of Sexton or Person in Charge f Premises ��t` ^1i�"I
%� (please print)
Signature �• Title (-1Zerr1111
(over)
DOH-1555 (02/2004)