Palamar, Mary NEV\YOR1I STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
Mar• G4oria Palama F -__,
Date of Death Age If Veteran of U.S. Armed Forces,
ili qg 1 p 1 12 L i 9$ War or Dates
n Place of Death M Hospital, Institution or
Cit�,�o m�ir Village 1 10(eaL Street Address �� G '� O� e �a'Cl part
Manner of Death Natural Cause t Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name ��h Title M._ Q IZu. - -
Address --
• 3-i to-7 Ms ,+r�_ k-—\ arrextsbu ro ,_ A)y I Zr
Death
Certificate Filed District Number ester Number
i
City, own ,r Village 1�O re(3�u t�
Date Cemetery or Crematory
Burial O$l 04 \ S-(3)-4 i?• i ne vie° C e me a•e,ry
Address
[1]Cremation Cremation \�2r _' OCt-C1 (1)-0-Dn our1 ►.1 .1�
Date j Place Removed
Z Removal i and/or Held
and/or
Address
Hold
0 Date i Point of —
0 Q Transportation i Shipment
Q by Common Destination
Carrier
❑Disinterment Date { Cemetery Address
Reinterment
Date 3 Cemetery Address
I
•
' Permit Issued to Registration Number
Name of Funeral HomeHccllard b. &t.ker Fw,ecctl Home_ 011 30
Address , Lafayette 31'• , O(,ua,nSbc l-r`j , /Ue.W L/Urk J . ??Uy
s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
. Address
Permission is hereby granted to dispose of the human r ains described above as indicated.
r}• Date Issued Q/S/// y Registrar of Vital Statistics /AA._ 44 6
Yt
(signature)
District Number e/S&2, Place 3 5/ Re y/10/a( 4a! , /np,C-C a u. NN /69j;21
i certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
fDate of Disposition 8/4/1 4 Place of Disposition Pine View Cemetery
2 (address)
W to Single Interment Sec. 2 198 1
CC (section) (lot number) (grave number)
AName of Sext n or Person in Charge off Premises Connie L. Goedert
(Please pant) Superintendent
44 Signature,. �.�/ -ed=�0 Title
(over)
DOH-1555 (9/98)