Albert, Marie e
NEW'rt, , -' ALTH • '
Vital Records Sew Burial - Transit Permit
-11141111111 --�®
- Name First Mai/� Mi `-'e E Last A fiber_ Sex
''"3 Date of Death ,1_ 1�O i J ' Age if Veteran of U.S.Armed Forces,
�q War or Dates
Place • Death Hospital sty utio er- ,
' - , Town _ :=- �-(l S� �x,vz.t-. s e�s 5�0.�1 ion N u.1 ligAc
tEl
•0,,- Manner of Deat o pi1 Natural Cause Accident 0 Homicide Q Suicide Undetermined Pending
Circumstances Investigation
119 Medical Certifier Name • Title /
Ci SU-z_an oft 6 )off fib
Address /' 11 Ctnbr ll r W. ( .r71t.obWl ti , .IV 7 /Gr s(L
at Death Certificate File Dis t Number Regi er Number
e C ,Town r Villag c(Q C
' Date n 3 �f ''Cemetery mate j-- 7)p
/�
:..curial 7/ I S f. 1 / )Or1 Su (c m, .
- Address ---—
Luzeine
.-_� Cremation
u.�. Y _ ,. -ate#_
Date Place Removed
Z❑Removal • and/or Held
2
and/or Address
Hold -
0 Date Point of
Q Transportation Shipment
3 by Common Destination
Carrier
.: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;'' Permit Issued to Registration Number
`'va Name of Funeral Home
`4_; Address
i fir Name of Funeral Firm Making Disposition or to Whom •
"' Remains are Shipped, If Other than Above
ri Address •
w
.
::n Permission is hereby granted to dispose of the human re ains described above as indicated.
EM
iN Date Issued F ( o ) Registrar of Vital Statistics j ,.....,
•
(signature)
``�Y c Place l Q Th d-c b_,I...,,,__
� District Numbe C9
r
I certify that the remains of the decedent identified al3ove were disposed of in acc rdance ith this permit on:
Date of Disposition 913 1t Place of Disposition SJI Al f ti•^Cur Ce,..<1,1, la 2 e n e Ql Q„ez,y 12.rj.
,a (address)
la P 2t, • Z.
cc (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises Pao/A L '
(please print)
1J Signature Title MMa/ -•1
(over)
DOH-1555 (9/98)