Tyrrell, Betty 4 . # pi
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ." Burial - Transit Permit
Name Firs Middle I,,ast Sex
Date of Death Age 9,i7 If Veteran of U.S. Armed Forces,
id — -2-6 — !' ( War or Dates /bl el
t- Place of Death Hospital, Institut nor 1� e/�}
City, Town or Village I )CO A/aQb1i,? . Street AddresILI
s -C'lJf.�Kv�+5� ,�.X,✓/��- '
Manner of Death Natural Cause 0 Accident u Homicide 0 Suicide �Undetermined Pending
i Circumstances Investigation
ul Medical Certifier 0(J / cam, Titl-�L
b Add ess Y / 1
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Death Certificate Filed �ti ) Distr ct }Ammer Regis Number
City, Town or Village 1 r C t v U de Yd�'r J'
❑Burial Date Cemetery or,Crematory
id' 04 '7j- 2e/�1 p/k'_tviee 'v, pro'v y
❑Entombment Address
remation L J° ..R-iaS b Nit
i
Date ace Remov
❑Removal and/or Held
and/or Address
C: Hold
Date Point of
i0 Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
>' Permit Issued to i / / Registration Number
Name of Funeral Home '�, L /V- f yt}'e v dmR- C _s--7 7
oilii Address .3 c� k � /NA /� !l_ y, / �F/
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Z.
itl
'' Permission is hereby granted to dispose of the human remains d s ribed abov i 'cated.
iili Date Issued /0 .2 —,d/ iegistrar of Vital Statistics ',' "nN�,-'1Y�
ignature (
iia District Number I c to 14 Place (\C
J
I certify that the remains of the decedentidentified above were disposed of in accordance with this permit on:
10
0I Disposition1�w�V l� Date of Disposition �0 �3 (Place of Nri ��
Z. (address)
W
ta
CC (section) lot ntfPnber) S (grave number)
ci Name of Sexton or Person in Charge of Premises moil--(p/e se par t)
-,
• Signature4 Title
(over)
DOH-1555 (02/2004)