Kenney, Grace NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First rti Middle Last j Sex
n - U A. 19-t--V C___ t.,-"C_E t//9- /( 6:k/A) 611,1 1'7C/782 '
Date of Death j Age If Veteran of U.S. Armed Fares
/34/ "2__ 9 ? War or Dates /f 4.A Place th Hospital, Institution or /j
�� City Town r Village 0 ,.>tJ S& Street Address 4' 9 C,�C. t ec C�iht-7'�"
0 Manner of Death Natural Cause Accide t D Homicide 0Suicide 0 Undetermined 0 Pending
l '� Circumstances Investigation
W Medical Certifier Name P Title
Address / ( e.7.,
Deats -_4.--cate Filed strict Number r� ester mber
Ci , Town a Village VW u .)S Q -- (c�
anal Date / (`Cemetery Crematory
6 /-) it?.._, 1....)ii- i Li...,,)
Entombment Address
['Cremation j
..: Date Place Removed //
Removal and/or Held
2 "9i
ir❑and/or Address
F. Hold
tit
O Date Point of
0 Transportation Shipment _
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to l� Registration Number
Name of Funeral Home NC.Vf1ofc� )). yak-er- Rnefa 30
Address tt
II L.tz4G.4((Cti-C S+rieet, cil bu / 1 Nicv 1(..., lg.:Rol-1
- Name of Funeral Firm Making Disposition or to Whom I
Remains are Shipped, If Other than Above
a Address
rr
ILI
Permission is hereI7 granted to dispose of the human emains described above as indicated.
Date Issued LO{ . -0 i Registrar of Vital Statistics '-_,.,_ C
_._.-fir (signature)
District Number c6 --) Place t 0 L>___, * A �,
I certify that the remains of the decedent identified above were disposed of in a itiance ith this permit on:
k
AuDate of Disposition 6/7/1 2 Place of Disposition Pine View Ce
2 (address)
VI Mohican 28 A 2
CC (section) (Jot number) (grave number)
p' Name of Sexton or Pers in Charge of Premises Michael Genier
�'+aJ.+G'y�,t�`� (please print)
1.11 Signature Title Superintendent
(over)
DOH-1555 (02/2004)