Bodenweiser, Mary f'W YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
H Qr V RuSC_ ell GU-C i Ser
Date of Death a_I 1 3 Age 0 z If Veteran of U.S. Armed Forces,
l
1 War or Dates
Place eath 1 HospitalTtitutio or
z . 1 Cit Town r Village . Ed ni C� Street Address For
+
N ud
Manner of eatl Natural Cause 0 Accident [i Homicide Suicide Undetermined 0 Pending
lid ��'� Circumstances Investigation
tu Medical Certifier Name t. f QU e� ' ` �Qn� Title Nip
41. Address l�� J v .
_ CCl-rep RA , C--\lens �alss N`/ taWI
Death cate Filed District Number _� Register umber
City, own o Village F-', L_0 wrd 7,5s
l :urial Date Cemeter or Crematory
a�poi 3 �It View
['Entombment Address ps,[ Cremation �� 0.k �.V-6 . ,_0 n- bL.uL -j/" 7 G‘p OL-%
Date ' Place Removed
Z❑Removal and/or Held
and/or Address
tt} Hold
0 Date Point of
tlt
Transportation Shipment
0 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to i t�, L Registration Number
Name of Funeral Home M�.(anaJdJ , �`�� r 1 o I i3L
Address i l L accu j s_. r,u,Lcn � �., Aw ovyl
Name of Funeral Firm Making Disposition or to Whom
�J
I.— Remains are Shipped, If Other than Above
2 Address
Q
W
a. Permission is ereb granted to dispose of the human r ains described ab ve as' dicated.
Date Issued Registrar of Vital Statisti
(signature
District Number j 5 Place / n ���
lF- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
ILIDate of Disposition 1 /26/1 3 Place of Disposition Pine View Cemetery
a (address)
Ui
Ca Mohawk 6&23 A 2
CC (section) (lot number) (grave number)
flName of Sexton or Person in Charge of Premises Michael Genier
(please print)
ill
9/ ^� Title Superintendent
Signature
(over)
DOH-1555 (02/2004)