Peterson, Maggie NEW YORK STATE DEPARTMENT OF HEALTH 41- --
Vital Records Section j ° Burial - Transit Permit
Name rst I)lliddle I act Sex
A styi e v%s-e__ l�hs0� FA-/rllJUL-
Date et
eath Age If Veteran of U.S. Armed Forces,
v L/ 13 a-tr/Er- fre.5 War'or Dates
1.- Place of Death / Hospital, Institution or ,
Z City, Town or Villag c�'�r'0� Street Address .96 a,,t, 'N e�Tfi c Dt"i U-�-'
tu
c Manner of Death N tural Cause El Accident D Homicide El Suicide El Undetermined 0 Pending
W Circumstances Investigation
W Medical Certifier Name, Title
o . SQ-A S C4cr)ti-,i AA) r'ri3
Address
fir.;r0-o rJ k,P Kam- fi e 1 rit sure V' eScC(y , p - 1U 7. I 2-9"7a
Death Certificate Filed � / District u be,,t Register N ymber
City, Town or Village <41 t--aa1J //JJ '
Date Cem or Crem�tory
❑Burial ��— �� ` �� %lv�. V/eio ek-, ,,,A `ov>.
Entombment
Address
(remation O e e_k_ i O 1r\// A•-
Date Place Rd:moved
Z ❑Removal and/or Held
and/or Address
F_- Hold
MY
0 Date Point of
n' Transportation Shipment
G! by Common Destination
Carrier
Disinterment Date Cemetery Addre'
D Reinterment Date Cemetery AddrE
Permit Issued to / / Registration Number
Name of Funeral Homo 4 rcy 4. T --,a4h/ JhIii� : _ ,rOSI7
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
f
iiii
P' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued '7 —/.3 --/f' Registrar of Vital Statistics (7.5 --U42c.0
(signature)
District Number / 63 Place 3 2,--0-eit
_ /ur
:::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI
o
Date of Disposition 7/j{�his Place of Disposition ��, .,, ---,I
(address)
ILI
1E (section) (Il number) (grave number)
cf Name of Sexton or Person in Charge of Premises At �t-"f'(
2 (plea a print)
f Signature 4
/�^ Title Airltik
:..:.::,,
(over)
DOH-1555 (02/2004)