Mousseau, Marguerite NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex F
h '(r 1t2. b� H®t t SSea,L"
Date of Death rb 1I I Age ci ! If Veteran of U.S. Armed Forces,
War or Dates
14. 54.EZ:ft_l_ivillage. � ���� ��� osp �sti#tia - r5sClensFa/ sfa ;-+a,1
ul
1t Manner of Death Iiatural Cause El Accident D Homicide D Suicide D Undetermined El Pending
Circumstances Investigation
lF Medical Certifier Name Title
c anie t V� ay M
Address fDO Par k-- f •j C Le ns ra_ 1 s AN/ /0 3o i
D h Certificate FiledC`Z�2X� �C�.�� DistrictjPbç Registo3ritl
Cit
Burial Date c I
q
I got 1 (Cemetery)a rematery p( V i 1 1 C 1n1 DEntombment Address
DCrcTation __ ck.0.lc54 r- 2A ,, CQ -U1Sbu_r_y 1\.1 1 a o
Date Place Removed
Z Removal and/or Held
2❑and/or Address
H Hold
til
0 Date Point of
D Transportation Shipment
ct by Common Destination
Carrier
D Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to 2 -- Registration Number
Name of Funeral Home IL/ n�-�� -a f ker r-tt,()erci / 7lOcr Oil .3o
Address 1 t La.k y e c, _i_,, Q(,,L.Q.,r) bu..f `i I 1�)0,4
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
E Address
it
ill
Permission is hereby ranted to dispose of the human remains de cribed ab ve 'cated.
pill Date Issued 0 .U oft/ Registrar of Vital Statistics 47 4'
(signature)
in District Numbera/ Place '''7,7 NUJ`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lLI Date of Disposition 9/9/11 Place of Disposition Pine View Cemeter Y
(address)
LLI
ta Mohawk 156 B 1
CC (section) (lot number) (grave number)
ciName of Sexton or Person i arge of Premises Michael Genier
(please print)
SignaturesQ Title Superintendent
(over)
DOH-1555 (02/2004)