Lewis, Merisa NEW YORK STATE DEPARTMENT OF HEALTh Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Firstiddle Last Se
............................................
Date of eath diAge If Veteran of U.S.Armed Forces,
. G* / 6 93 War or Dates
Place of Death Hospital, Institution r. ........................ .................................................................
City,Au Town or Village Street Address T
> Cause of Death �X�, ..........
U
w Medical Certifier ame Title
::>:>:
Address
:::::::::>:
Death Certificate Filed �- District Number Register Number
City,Town or Village fie...,„,/a -S`7. . 1 3`f S'
Date Cemetery Crematory
Burial 731 g'9. .
? 1..:::.;....::::.:.:::::.:::.::.:...........:::.
Cremation Address
! U
>z Date ace Removed
OI ❑ Removal and/or Held
and/or Hold
Address
t.
Date Point of
rn ❑Transportation by`. Shipment
Common Carrier
. Destination
❑ Disinterment Date Cemetery Address
.....................................:>:::Date:::::.....................................................::.::.C88::. :,::::.....................................................................................................
❑ Reinterment em try Address
Permit Issued to Registration Number
::::::::::
Name of Funeral Firm r 3'
Iiiiiiiiii Adds / /'
7........../...(--d 1.p „,,.., .-,t. ..:4.::::::::::: .: :.../ ::.(Ff�:::::::::::::::::::::::.:.:,::::::.:::.:::::::::::::::::::::::::::::::::::::::::::.:.::.
.i4 Name of Funeral Firm Making Disposition or to Whom
imi Remains are Shipped, If Other than Above
Address
U:
Permission is hereby granted to dispose of the hu ma __re ains es ib,:d above as indicated.
Date Issued .3/g./ Registrar of Vital Statistics �4 .m (; - '
ignature)
O r,�� . 1.
District
Number --a / Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 12804
).
!w Date of Disposition 7/3/89 Place of Disposition St. Alphonsus Cemetery, Luzerne Rd., Queensbury, NY
address
w> Single Gr(address
Section South of Edward Dinneen
•I (section) (lot number) (grave number)
CC>
QName of Sext n or Person in Charg= of Premises Rev. Joseph A. Falletta
Z //`` i/ �� (Please print)
Signature L( . y Title Pastor
DOH-1555(9/86)p 1 of 2(formerly VS-61)