Rousseau, Marie NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First yy��,, Mid,Ile Last Sex
liiiiii
Date of Death Age If Veteran of U S Armed Forces,
Dc. } q 3 f. War or Dates ti I
Z Place of Death 1 Hospital, Institution or Q
Ltt Gity.Town or Vrl}soe G y- /7 if e. Street Address (e PI' '1/:. !/,r.f:�!. / 4 3 --
G Manner of Death 1Natural Cause Accident ❑Homicide Suicide Undetermined ending
W Circumstances Investigation
oMedical Certifier Name Title
C°. .6 ,6 4- 1.41, .::
mi Address....................414...7.....
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Death�Certificafe Filed District Number Re stet Number
.6ity,Town or Vittaga-- /?/1 v, it e- ,j--7 Sfr 3 3
Date Cemetery or Crematory
❑Burial . .�+ ?:.c3 ff l �f /�3 c`.. f C� r Prri l� 4v.�
�remation Address.
6 u.P-Purl 6ce r
z Date Place Removed
O 0 Removal and/or Held
i- and/or Hold :: .. ..- ::..
Address
N
t3L Date..,:::_ ..... .,: Point of
CO 0 Transportation by
p Common Carrier -::... Shipment
Destination
El Disinterment
Date CemeteryrAddress
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm fib,�j.P, - ,f �i yef�rIr e,a /I e O /o
:...' Address
c79 3 C4 u r-c4 6,-a gG `/Ie , ,u 7 1 2 S 3 `L
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# .: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
X• Address
W>
Permission is hereby granted to dispose of the human remains descri above as indicated.
Date Issued t)ebc. 3 I Q 2' Registrar of Vital Statistics ~7/27 `�' z,(
(signature)
iiii District Number / S " Place 13Ze1h o 6v-4/7 a ,' j/e___
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition ,v- d 3 Place of Disposition /� / een-1-pnye /z),Ay
E (address)
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cn
cr (section) (lot number) (grave number)
pName of Sexton o�Person in„Charge of Premises 4 _�'1/%'�/i f' /),/f f/r,4..1
W ( .,__..—�--�� (please print) _ ���� / �--
Signature ;.f�\ ./1,�yy�r- t.-:9 Title >f �`��/7 i / 1 f
DOH-1555 (10/89) p. 1 of 2 VS-61