Cohen, Marilyn NEW PORK STATE DEPARTMENT OF HEALTH ._ .. �Vital Records Section Burial - Transit Permit
Name First Middle Last Sex �Maxi I 1� y) P\,t C, en
Date of Death Age Tf Veteran of U.S. Armed Forces,
1/17/13 cl(61 War or Dates 110
-- Place of Death Hospital, Institution or
U City, Town or Village \ QMStreet Address £c(,dy ��ji•3;nc C-eYl -n'
a Manner of DeathLL. Natural Causie El Accident ❑Homicide ❑Suicide ElUndetermir{ed ❑Pending
Circumstances Investigation
ig Medical Certifier N me Title
Address
2oc)s rh 4v-e TIIof KO I ZIg0
Death Certificate Filed District Number Register Number
City, Town or Village L/rQ 2- Li s I
Burial Dateqii9 1 /3 Cemetery or Crematory
Y‘Ctar(A_Al -re t(A_
❑Entombment Address,,,
__ _ o`��Y\Sbw(-
Date j Place Removed
Z.ri Removal and/or Held
2 and/or
� Address
Hold
to
Date Point of
ti❑Transportation Shipment
0 by Common Destination
iiiS Carrier
El Disinterment Date Cemetery Address
iiiiii ❑Reinterment Date Cemetery Address
iii8iPermit Issued to �(� c m r Registration Number
Name of Funeral Home I \€96(1 V J`)-ctc O r oft �`F. I-1 , 3 I )L/3
is Address 5-3
J C, vLa__f_r Rd, -eensbi,r j io r 2 ti l o
mi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
2
w
Permission is hereby granted to dispose of the human remains described above as indicated. elsn
Date Issued t7/1 7//3 Registrar of Vital Statistics 7:-/
igna ure)
District Number 4/0 2, Place �d ti
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition alace of Disposition 7( j�, (2
M `�( d ss)
C (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Jt`:_m h U a...- ( ,e--De 2
2 t (please print)
iiiii Signature4_1" Title linu Q- oU C(-'r 1�
(over)
DOH-1555 (02/2004)